Shaun Woodward: Because its contents remain a matter for the independent inquiry, of course I have no idea what will be achieved in relation to those contents. However, I can tell the hon. Gentleman that I am concerned about the costs. As a result, working with the inquiry, I have now arranged for the office in Northern Ireland to be closed, the size and costs of the accommodation in London to be significantly reduced and the IT contracts to be renegotiated. We will therefore make savings of about 20 per cent. of what would have been spent in the remaining months.

Peter Hain: May I ask my right hon. Friend about any lessons that could be learned from the tragedy that the Saville inquiry is investigating? Is there any read-across to the inquiry by Sir Peter Gibson into the Omagh bombing, a statement on which was made this morning? That statement seems to have exonerated GCHQ from any of the allegations made by the BBC, among others. It seems that if there was any malpractice or any problems, they were more on the Royal Ulster Constabulary special branch front, which was largely addressed by the 2001 reorganisation. Does my right hon. Friend agree about that?

Shaun Woodward: May I take this opportunity to congratulate the Select Committee on its recent report, which rightly raised a number of these issues? It may be helpful if I inform right hon. and hon. Members that next week, we expect Lord Eames and Denis Bradley's Consultative Group on the Past to publish its report on the way forward. The Government look forward to that and will be studying its proposals carefully.

Gregory Campbell: The Secretary of State has referred twice to getting at the truth. Given the exceptional difficulty, if not impossibility, of doing that in all the inquiries, and given that the inquiry industry in Northern Ireland is blossoming to the extent of costing £60 million a year, does not he accept that it is time to call a halt to the past and look to the future?

Shaun Woodward: I am sure that many hon. Members share the hon. Gentleman's concern about the amount of money involved. However, I caution against the use of the pejorative description of an "inquiry industry" simply because, although some may regard it as an industry, for the families affected, the victims and those whose lives have been destroyed by the troubles, it is essential to find ways to get at the truth. There may be better ways of doing that in future. If we can find ways that provide better value for the taxpayer, we have a duty to do that. However, first and foremost, we have a duty to do all we can to provide justice for families, and for victims who needlessly lost their lives during the troubles.

Gerald Howarth: The Secretary of State has referred to the families, but not to the former soldiers, some of whom are my constituents. For 11 years, they have had the threat hanging over their heads. I spoke to some of them this morning. They did their duty by their country but they feel that the Government have not done their duty by them. Will the Secretary of State please at least send a message to them that he understands their concerns and those of their families and do something to reassure them that the matter will be brought to a speedy conclusion? They are now in their 70s and some have already died. 1 Para has a reunion next month—please give them a positive message.

Shaun Woodward: The hon. Gentleman has been unstinting in his advocacy for the work of the security forces. May I again put on record my admiration for the way in which our security forces have responded over many years to terrorism in Northern Ireland? Undoubtedly, there are lessons for us all to learn from mistakes that may have been made, but the support of the Government and the House for our armed forces has been and remains unshakeable.
	The hon. Gentleman mentioned the concern that some of those to whom he spoke expressed. It is a matter of parity that, just as I am prepared to meet families from Derry to discuss arrangements for publication, if he would like in future to bring a delegation to meet me to discuss that, I would be more than happy to do so.

Paul Goggins: I readily join my hon. Friend in paying tribute to the Parades Commission, and especially to its chairman, Roger Poole, for its unstinting efforts to ensure that we have peaceful parading in Northern Ireland. It is worth reflecting on the fact that the Whiterock parade, which went so dreadfully wrong, happened only a little over three years ago. Everybody has worked hard for those three years to ensure peaceful parading in Northern Ireland, but we have made it clear that, if there is a consensus about an alternative system for regulating parading and having oversight of it, we are prepared to consider it. Lord Ashdown has been given that task, and I hope to receive his report in due course.

Jeffrey M Donaldson: The Secretary of State will be aware of the very strong opposition of the Police Federation to the extension of this legislation, which comes after attacks on police officers and the intimidation of police and prison staff by those connected to loyalist paramilitary groups. My party is not convinced about the extension of this legislation. Can the Secretary of State give us any evidence that the loyalist paramilitaries are now in a position to decommission their weapons?

Shaun Woodward: I am sure that all Members of the House would wish to express their gratitude to the men and women of the PSNI. It remains a matter of fact that the greatest threat to those officers, as expressed in the last year, has come from those paramilitary criminal organisations such as the Real IRA and the Continuity IRA. They are the organisations that have despicably, and in a cowardly way, attacked police officers at traffic lights when they were dropping off their children at school. They have fired shots into the chest of one police officer who is very lucky still to be alive. In another case, an explosive device was placed under an officer's car and his partner was nearly murdered by it. PSNI members do very brave things for the people of Northern Ireland and this country every day, and we will do everything we can to protect the lives of those brave men and women.

Shaun Woodward: I do not know whether the hon. Gentleman has a hearing difficulty, but as I have just explained to him, it is advice to us from the commission that has ensured that, on balance, we have made this decision. In my last answer, I made the offer to the hon. Gentleman that it would be possible through the usual channels to discuss with him further details, but if he really thinks it would be helpful for me to make public now the content of discussions that might result in guns being removed from the streets, I have to question what his motives are. If his motive is to remove the guns, I suggest he listens to the advice from the commission. On the other hand, if his intention is simply to proceed with a decision he made before that information emerged, I am afraid that even I am unable to help him.

Gordon Brown: To commemorate Holocaust memorial day, there will be a debate in this House next Thursday. I was very privileged to be involved with the original funding of the Holocaust memorial trust's work in education, which enables us to send, from schools in every part of the country, young men and women to see for themselves at first hand what happened at Auschwitz and then to report back to their fellow students in their schools and colleges. This is an important contribution in ensuring that people will never forget the millions of lives lost as a result of anti-Semitism, prejudice and discrimination.

Gordon Brown: I should explain to the right hon. Gentleman—and he has the benefit now of a new shadow shadow Chancellor to help him on his way— [ Laughter. ] I should explain that when markets fail and banks are unable to do the job for which they are intended, the only agency that can step in is the Government. If the Government do not take action, no one else will. That is the lesson that has been learned in every single country of the world, and that is the lesson that President Obama said yesterday is the work that will be pursued in America.
	On the action that we have taken on banks themselves, every guarantee that we have made is set against the banks' assets. In the insurance policies that we have signed there is a fee, and every loan is to be paid for as a result of the credit that we have extended. The right hon. Gentleman referred to the asset purchase scheme, and what we actually announced on Monday was a process by which we will talk to the banks in individual detail, and we will look at their assets and liabilities with them. We will therefore conduct the audit of the banks' finances that he says is necessary. We will report back to the House on the nature of the insurance scheme that we agree, and the risks will be shared with the banks in the scheme. It is similar to schemes that are being adopted in other countries, and which may continue to be adopted in America and elsewhere. I believe that it is the right thing to do, but the right hon. Gentleman must decide which central proposition he agrees with—that the recession must take its course, or that, when markets fail, Governments must step in.

David Cameron: The fact is that this recession is getting worse. The Prime Minister talks about action, but the fact is that when we suggested a national loan guarantee scheme, he attacked it—and he has now introduced it. We suggested changing the terms of the bank recapitalisation; he attacked it, but he has now introduced it. We said that he needed to extend the special liquidities scheme; he attacked it, but he has now introduced it. The fact is that he is behind the curve on every single issue.
	I am delighted that the Prime Minister has mentioned my right hon. and learned Friend the Member for Rushcliffe (Mr. Clarke). The difference between this former Chancellor and that former Chancellor is that this one left a golden legacy and that one wrecked it.
	The Prime Minister said that the insurance scheme was a temporary measure. His City Minister, Lord Myners, said that it could last for up to nine years. How can the Prime Minister describe something as temporary that might last for nine years?

Gordon Brown: I was very grateful for the support that the Opposition party gave to the recapitalisation of the banks three months ago. I suppose that I should not be surprised that the minute there is a difficulty, it withdraws its support from the right proposal. The recapitalisation of the banks was the right thing to do. The right hon. Gentleman has no other policy that would replace that policy. We are right to continue to support the banks so that they can lend to people in this economy, and the measures that we have announced this week are the right measures to take us forward.
	The right hon. Gentleman is completely isolated from every major party in every country in the world. Every country understands that when the private sector and the markets fail, and particularly when banks fail, the Government have a duty to act. He wants to cut public investment while others want to increase it. He wants to withdraw help from the unemployed while we want to give it. As far as the banks are concerned, he does not know what his policy is because it changes from one day to the next.

Andrew MacKinlay: Were the Serious Organised Crime Agency, the Financial Services Authority or our security and intelligence services fast asleep, or were they part of a cover-up in relation to Lloyds TSB's illegal handling of money from Iran to get round sanctions? Surely we need a statement about why this bank—and no individual has been prosecuted in the UK—laundered in America $300 million of Iranian money and money from London that related to the Sudan. I think we should be told.

Nicholas Clegg: I am grateful to the Prime Minister for his reply, but does he not see the extreme danger in any remaining ambiguity in the Government's response? Does he not agree with me, and the Chair of the Treasury Committee, that that must now mean the full, if temporary, nationalisation of our weakest banks without any further delay?

Gordon Brown: The issue is the extension of lending; that is the issue before us. The agreements that we have signed with the banks already are, I believe, agreements that are being honoured at the moment. I have to say to him that the problems is that when the banking crisis started, foreign banks that were operating in Britain reduced their capacity in Britain. Non-banking institutions that were lending in Britain for mortgages and companies reduced their capacity, so even if the Royal Bank of Scotland, Lloyds TSB, Barclays or those other banks increased the capacity substantially, we would have suffered a loss, just as every other country has suffered a loss of foreign capacity. That is the problem that we are trying to deal with. The problem is the resumption of lending; that is still the problem that has to be dealt with, whatever the status of the banks.

Bob Spink: Fair's fair: we must all welcome the action that the Government are taking to get money flowing into small businesses and to keep people in work. The Prime Minister is doing that to help small businesses, not fat cats, but may I press him on behalf of pensioners, who also suffer from the recession? Will he meet me and Age Concern so that we can look at ways of further helping pensioners on issues such as meeting their fuel costs and on savings interest. Will the Prime Minister meet me to do that? Doing something constructive is much better than doing nothing.

Gordon Brown: I am grateful for the hon. Gentleman's question.  The Sun said only a few days ago that there was only one MP who was more independent of the Conservative party Front-Bench positions than him, and that was the right hon. and learned Member for Rushcliffe, now the shadow Business Secretary. With reference to pensioners, we have increased the winter allowance this year—£60 extra is going to pensioners now. We have also increased the pension from April. We will do everything we can to help pensioners with their savings. That is why we have the individual savings accounts for pensioners, and we have raised the pensioners' tax allowances so that 60 per cent. of pensioners pay no tax at all. We will do everything we can in the next few months to help them. The hon. Gentleman is an Independent Member, so he, like those on the Labour Benches, can criticise the Conservatives for not supporting the £60 extra that we are giving to pensioners.

Gordon Brown: I believe the international community has to show great unity in isolating Iran, not only for the position that it takes on nuclear weapons but for its attitude to Israel. The best way that we can isolate Iran in the middle east is by finding a settlement between the Palestinians and the Israelis, whereby the middle east countries and the Arab countries can become united in supporting the two-state solution that other people have proposed.
	Since the ceasefire, it is important that Israeli troops leave Gaza as quickly as possible. It is important that the crossings are opened. That is being discussed at meetings in Egypt tomorrow. It is also important that the peace process is moved forward. Although this may seem one of the most distant prospects at the moment, I believe we have a duty to use this opportunity to get countries to talk together about the process of peace. But the most important, urgent thing is the humanitarian aid that must be brought into Gaza. We have trebled our support for humanitarian aid, we are helping to transfer children from Gaza into hospitals, we are trying to get rid of the unexploded bombs in the area by working with people in the region, and at the same time we will give all the food aid and all the support aid we can. There has been a terrible catastrophe over recent weeks. We must do everything we can now to help the people of Gaza, while at the same time stopping rocket attacks from Gaza into Israel. We must see that the ceasefire holds and then brings forward the process of peace.

Paul Flynn: On a point of order, Mr. Speaker. May I raise with you a matter of the gravest importance that arises from your duties to protect the rights of Back Benchers? This is an instance in which the right of Back Benchers to scrutinise Government decisions has been obstructed in a most serious and deliberate way.
	You were kind enough to allow me a debate in November on the decision to grant a novel indemnity to the American-led company that has taken over Sellafield, an indemnity that could cost taxpayers many billions of pounds in the future. At the time, I raised the concern that I, along with other Members who had shown an interest in the subject, would have no opportunity to debate it in the House because the minute came from the civil servants, from the Government, 75 days after the final day on which we could raise objections.
	In the Adjournment debate, the Minister said that that was simply a clerical error. Now, 140 pages have been released under freedom of information legislation, many of them heavily censored, but it is clear from them that this was a deliberate, calculated attempt to ensure that the House was not informed about the decision until after the recess when no objection could be raised.
	It was also suggested in the document and the debate that informing a single Chairman of a Select Committee is a substitute for informing the entire House, but the decision of one Select Committee Chairman, however distinguished, is no substitute for the historic right of Parliament to decide these matters. This a matter of the gravest importance, involving a contract of £22 billion, and possibly a £1 billion-plus subsidy for taxpayers in the future. Will you, Mr. Speaker, ensure that there is some way of reversing this decision, certainly calling the Minister to the House to explain how the rights of Back Benchers have been so flagrantly abused?

Autism Bill

Andrew Lansley: I beg to move,
	That this House acknowledges the excellent reputation of emergency and urgent care services in the UK; commends the expertise and dedication of NHS emergency and urgent care staff who work around the clock to provide a consistent and reliable service; notes the strain placed on accident and emergency departments across the country from winter viruses, and commends NHS staff for their extra efforts to maintain services in the face of such pressures; supports the improvement of acute hospital services and development of specialist centres where appropriate; welcomes the recent report published by the College of Emergency Medicine, but notes with concern its conclusion that proposals for urgent care centres are clinically unproven and undermine the principle of patient choice; regrets the lack of evidence to support models of service configuration which are centred on financial concerns and pressures arising from the European Working Time Directive; deplores the Government's lack of urgency in addressing concerns raised over trauma care; believes that the public should be given a more meaningful voice over the provision of local emergency services; recognises the unique contribution made by community first responders; recommends that the Government introduce a single number to access urgent and emergency care services; and urges the Government to publish its delayed urgent care strategy, the consultation for which was published over two years ago.
	In this, the first Opposition day debate of this Session, we have the opportunity to reiterate our support for the national health service, which is our No. 1 priority and that of the people of this country. Even in the midst of economic crisis, we must be aware of how vital it is that all of us can continue to call on the NHS when we need it, and to know that its staff will respond with the capacity required, as well as the commitment and compassion that they have always shown in treating us as patients when we go to hospital or otherwise access the NHS. That is never more necessary than when we need emergency care for ourselves or for our families. Over recent weeks, we have seen great pressures on the service, with cold weather; widespread infections; wards closed by norovirus; an influenza outbreak; staff, as a result of that and otherwise, falling sick; accident and emergency departments that have been stressed 24/7; and, consequentially, elective operations being cancelled.
	Throughout all that, doctors, nurses and other NHS staff have coped and cared. I therefore want to start by thanking NHS staff, as many Members will have done personally in their constituencies. Right at the turn of the new year, I had an opportunity to visit Ipswich hospital and to speak directly to the staff working in the A and E department there, to thank them and to hear from them about all the pressures that I mentioned. To give the House an illustration of what this has meant for staff, I note that Sally Ferguson, who is chief nurse at Bradford Royal infirmary, said:
	"Our staff have been working very hard, are working additional hours and we have delayed some non-urgent, planned operations. Our staff have shown incredible dedication and a massive thank-you must go to them."
	We should not forget ambulance staff, for whom this has been an incredibly difficult time. Let me read this quote from Rob Ashford, who is chief operating officer at west midlands ambulance service:
	"Many of our staff gave up their own time to work additional hours away from their families while others enjoyed themselves."

Philip Davies: I am grateful to my hon. Friend for thanking the staff at Bradford royal infirmary for their hard work. I can confirm that they work incredibly hard under difficult circumstances. Will he join me in thanking the staff at Airedale general hospital, which my constituents also use, because the staff there do an equally good job as those at Bradford royal infirmary?

Andrew Lansley: I am grateful to my hon. Friend. Staff at Broomfield hospital, which serves his constituency, will greatly appreciate his comments. I know from talking to staff across the NHS that we sometimes underestimate the contribution that is drawn from all its professions and ancillary staff. We simply cannot run hospitals without a wide range of staff being present in order to make it happen, particularly out of hours and at weekends. Services can slow down dramatically without ancillary services such as diagnostics, portering and cleaning, and pathology laboratories being available. They are critical to maintaining the level of service that we all hope to receive when we go into hospital.
	Today, I want not only to express our thanks but to take the opportunity to make real our appreciation by understanding what the pressures experienced over recent weeks tell us about the capacity of the service, the impacts of Government policies and plans on emergency and urgent care services, and the need—which I express on behalf of NHS staff—for the implementation of long-overdue reforms to emergency care and its support structures.
	Let me give the House an important example in relation to understanding the pressures. In London, primary care trusts have been commissioning services from hospitals based on the framework for action that was published by Lord Darzi in July 2007. It is interesting to make a comparison, in order to understand what is going on. I heard from an NHS trust in London that its accident and emergency attendances in the 11 weeks before Christmas were up 10 per cent. on the preceding 11 weeks, that the elective admissions to the hospital were 15 per cent. above the level predicted by the primary care trust, and that its A and E attendances, year on year, had gone up by nearly 10 per cent., even though the primary care trust had said that they would go down.
	Lord Darzi's report said that, over the next 10 years, the number of attendances at A and E departments in London would go down by 60 per cent. He said that 10 per cent. of patients did not need to be seen at A and E, and that 50 per cent. would be seen in the Government's new polyclinics. Frankly, that is not happening. The number of attendances at A and E departments is going up.
	Up and down the country, people in A and E departments have told me that, when it comes down to it—as it often did over Christmas and the new year—patients are not being treated in the community when they are seriously ill, or when they are just reasonably ill, if the services in the community are unable to function 24/7 to offer the necessary support. The emergency department is the provider of last resort. It cannot say no; it has to meet the demand that is placed on it.

Andrew Lansley: I am grateful to my hon. Friend for making that important point. In this debate, we need to press the Government. She will note from our motion that we want the Government to introduce proposals for a new, single telephone number for NHS services. I agree that telephone access to the NHS is necessary, and that it is beneficial to patients, but we should not delude ourselves that it leads to a reduction in A and E attendances. There is no evidence that it does that, but it is an important additional means of access. However, having a single telephone number to provide direct access to ambulance services, out-of-hours services and telephone advice would mean that patients would not have to move from one service to another, resulting in long delays while their needs are interpreted in order to decide which service should respond. Such a single number is sorely lacking. Emergency calls should still go to 999, but it should be possible for a call to the single number to be upgraded to receive an emergency response if necessary.
	We know that that is necessary, and I think that the Secretary of State would agree. We recommended it some time ago and it has been reflected in subsequent next stage reviews across the country. The Government just have to get on with it, and for some absurd reason, when they have already accepted part of our motion, they seem to have taken it out, suggesting that they are not going to do it. They should do it. The next stage review by Lord Darzi said that it would happen, but there has been no consultation by Ofcom on access to a new single number, which we need; I hope that it will be provided soon. At the same time, we need a document from the Government showing how that number can provide access not only to NHS Direct nationally, but to out-of-hours services, local services and ambulance services. If the Secretary of State wants to interrupt me now to tell me that the Government are going to make progress on a new national telephone number for accessing urgent care services, I would be happy to give way to him.

Andrew Lansley: My hon. Friend reminds me that I visited Queen Mary's in Sidcup in the autumn, when I had the opportunity to see the emergency services and maternity services proposals at work. Many people in south-east London will be concerned about emergency services because, leaving aside the geographical distribution of emergency services in the area and the question of access at normal times, they will worry about the capacity of those services to respond. That is part of the argument about A and E in London more generally. Many dramatic pressures and a lot of demand have been put on emergency services. The number of beds in hospitals in London has been cut and departments have been downgraded.
	The right hon. Member for Enfield, North (Joan Ryan) will know that the Government are trying to downgrade the emergency services at Chase Farm hospital in her constituency to an urgent care centre. Just before Christmas the College of Emergency Medicine published a document on the way forward for emergency medicine and it did not regard urgent care centres as clinically proven or consistent with the principle of patient choice. Emergency consultants in hospitals are criticising urgent care centres, so why are the Government persisting with them? I fear that we will see the same problem in Sidcup.

Andrew Lansley: My hon. Friend is very knowledgeable about these matters. I have discussed the issue with him and with the chairman of his primary care trust, who believes that community teams will be able to look after patients in the community and, as a consequence, avoid their admission to hospital. Let us look carefully at the experience of the past few weeks and find out whether it is possible to do that in practice. In reality, we have seen patients being admitted into hospitals all the same. I am sure that Ministers will know that many patients in hospitals have been transferred into escalation wards because of limited capacity; they are having to create new capacity.
	Quite often, community hospitals can provide a place to which patients can be transferred to relieve pressure on acute hospitals when demand is high, while at the same time they can provide a sort of step-up bed so that GPs can admit patients and observe them. That means community medical resources can be deployed through GPs to look after patients, instead of those patients having to be transferred to an acute hospital, which is the last place we would want many of them to be. Let us look at what is happening in Wiltshire, because a lot of beds have been lost in hospitals in my hon. Friend's constituency, and I wonder what the consequences of that loss have been.

Andrew Lansley: Let us stay in this century shall we? The College of Emergency Medicine said in its report:
	"We find the term 'Urgent Care Centre' misleading with no clear definition of the case mix, staffing or how they relate to the emergency departments. There is no evidence of the clinical or financial benefits of this model."
	That is, however, precisely the model being pursued at Chase Farm. That model is being challenged locally by my colleagues and by the local authorities through judicial review, and it is incumbent on the Government, not least given the views presented by the College of Emergency Medicine, to call a halt. Given the pressures on London, they should reconsider whether Chase Farm should have a maintained emergency department, to meet demand.
	As for what is being done by the strategic health authority in London, Ministers, in their amendment to our motion, do not seem to be responding to the pressures experienced by emergency departments in London by saying that they can help them. They are responding by calling them to a meeting, hitting them over the head and saying, "You must meet the four-hour target". There are some excellent hospitals in London that are doing their level best to respond, and doing all they can to treat patients as quickly as they can. It is far from helpful for them to be threatened by the strategic health authority because they are at 97.1 per cent. rather than 98 per cent. The College of Emergency Medicine has argued for a long time that in practice, a 95 per cent. target for the four-hour waiting time in accident and emergency departments is financially and clinically logical.

Alistair Burt: I am grateful to my hon. Friend, who has been extremely generous in giving time to colleagues. Before he leaves the issue of time pressures in the health service, I can confirm, from visiting Bedford hospital in the Christmas period, the pressures caused by the implications of the working time directive. Does he share my bewilderment as to why Labour MEPs did not vote to continue Britain's opt-out from the working time directive, knowing the implications for the health service and the problems that it would cause?

Andrew Lansley: My hon. Friend makes a vital point. It is astonishing that Labour MEPs would not adhere even to their own Government's policy. That came after the Government's presidency of the European Council, when they were unable to deliver the required changes to the directive. A compromise was agreed in the Council of Ministers, but the Government appear incapable of getting it through the European Parliament. It is outrageous that British MEPs should vote in a way that damages the prospects of delivering care in our NHS.
	In the light of all the pressure on A and E departments, we have to ensure that they are not downgraded or closed unless what is done is evidence-based. I know that Ministers will say that because some patients need to be referred to specialist centres, such as for major trauma, paediatric intensive care, severe head injuries, heart attacks and strokes, all patients with severe illnesses or injuries should therefore go to a regional specialist centre. The evidence does not support that. For example, the Sheffield study in the  Journal of Emergency Medicine, published in 2007, concluded that increased journey distance to hospital appeared to be associated with an increased risk of mortality, the strongest association being for patients with respiratory emergencies. The study did not include cardiac arrests.
	The argument is clear for an understanding that some patients will bypass their local emergency departments and go to a specialist centre, particularly those in blue-light ambulances. Let us contemplate major trauma. It is very important to have regional trauma centres, and we need the trauma network to be developed in that way. We saw in a report published in November 2007 that less than half the patients suffering major trauma received the best standard of care. That was according to the national confidential inquiry. The report called for regional planning for trauma networks, but what has been the Government's response so far? A Minister in the House of Lords said that they were considering appointing another tsar to take on the task. We are more than a year on, and the Darzi review provided plenty of opportunity for something serious to be done about the problem, and for regional work to make something happen—but that simply has not happened.
	We have been fighting accident and emergency reconfigurations. I give credit to my colleagues, because in Surrey and Sussex, for example, they have seen off plans that would have substantially undermined local capacity to offer emergency services. They have been fighting such plans elsewhere, such as in Hertfordshire, but I am afraid that they do not seem to have won so far in places such as Hemel Hempstead and Welwyn. I promise my colleagues, the House and the public that we, as a Government, will focus on ensuring that capacity is in place for the emergency services, and on not making accident and emergency reconfigurations unless they are backed by the decisions of local commissioners, such as the GPs who look after patients, and by clinical evidence of need. We will operate on that basis, and where necessary we will put a stop to misguided reconfiguration proposals.

Andrew Lansley: I understand the hon. Lady's point, but I think that she does us a disservice. My hon. Friend the Member for Hemel Hempstead (Mike Penning), not least, has made clear our determination to pursue prosecutions. To my recollection, there are something like 55,000 assaults a year on NHS staff, less than one in 1,000 of which leads to a prosecution. What is the point of putting up notices across NHS buildings saying that there will be zero tolerance of assaults on NHS staff if people know that in practice, those who commit exactly that offence will not be prosecuted?
	We make it clear in our motion that we want an urgent care strategy. The Government have promised that; they held a consultation in October 2006 and published the responses six months later. Two years on, they have not published a strategy. They said that the matter would be dealt with in the Darzi review, but the final Darzi report contains two references to urgent care, which are essentially nothing more than references to the single telephone number that I have already talked about. Where, then, is the urgent care strategy that is required? Everywhere I go across the country, people are looking for urgent care networks and for a better structure of urgent care that better knits together A and E, walk-in centres, out-of-hours services, ambulance services and NHS Direct, and presents seamless joined-up care for patients. It is vital that we achieve that.
	I thank the Government because they have accepted the first part of our motion in their amendment, and I appreciate that. Indeed, they have expressed their recognition of the work of community first responders. In some parts of the country, such as Cheshire, that is not reflected in the behaviour of the ambulance service. Community first responders in rural areas make a vital contribution to response times, especially category B response times, but their achievement does not appear to be recognised. However, I appreciate the Government's approach to that.
	Despite that approach, the Government have gone on to delete a great deal that is necessary in the motion and replace it with some deeply flawed text. They persist with the idea that improvements in primary care and access to GPs is a substitute for access to emergency departments and emergency care. That is not the point, as the College of Emergency Medicine makes clear. It stated:
	"It is disingenuous to compare a 24/7 service that cares for the whole spectrum of ill and injured patients with the care of routine patients in a GP surgery."
	"Disingenuous" is not a word that I would normally apply to the Secretary of State. The idea probably emanated from the Minister of State, Department of Health, the hon. Member for Exeter (Mr. Bradshaw).
	I hope that we have shown that we appreciate NHS staff who work in emergency care. I think that we show that we appreciate them if we listen to them. They need a major trauma network, but the Government are letting action on the national confidential inquiry report drift. The urgent care strategy and the single number seems to have been delayed and delayed, and the Government's assumption that patients will not turn up at accident and emergency has been proved false and—worse—dangerous. With beds being cut and A and E departments downgraded, the capacity to deal with surges in demand is being undermined. The evidence from the College of Emergency Medicine about A and E reconfigurations, which was published in December, is being ignored and the Government persist with their plans for urgent care centres in place of emergency departments, although the case for that is clinically unproven.
	Emergency departments are central to the emergency care system. Instead of ignoring the views of emergency consultants and pushing polyclinics as a panacea for all ills, the Government should give emergency care the support and the structure that it needs to meet the demands that it faces in future. We will listen, not lecture. We will work with the evidence, not ignore it. We will act where the Government have drifted. I commend the motion to the House.

Alan Johnson: I am afraid that the hon. Gentleman is wrong. America spends 16 per cent. of its wealth on the health service—[Hon. Members: "Outcomes."] It has the poorest outcomes in the world for many health matters.
	The Conservative party has crossed the Rubicon and supports a taxpayer-funded national health service, free at the point of need. The predecessors of the hon. Member for South Cambridgeshire, in the shadow Cabinet and when the Conservatives were in power, would have had a range of hon. Members sitting behind them who might have paid lip service to that but who were carefully making plans to undermine it—whether through the patient's passport or all the other variations on that. I therefore welcome the hon. Member for South Cambridgeshire back. I am glad that he was not moved to make way for the right hon. and learned Member for Rushcliffe (Mr. Clarke)—although, if the right hon. and learned Gentleman had taken the post, the love-in with the BMA would have ended quickly, given his previous record.
	The hon. Member for South Cambridgeshire recognised that we support six of the 11 points in the motion. The Opposition commend
	"the excellent reputation of emergency and urgent care services in the UK",
	and rightly pay tribute to NHS staff, especially given the winter that we have had. I shall say more about that shortly. The motion also
	"supports the improvement of acute services and development of specialist centres where appropriate".
	That is rather confusing, because specialist centres, especially specialist A and E and the need to ensure 24/7 cover by the very best people, form part of the debate that has gone on in the health service—and I think, from his comments and propositions, that the hon. Gentleman supports that. However, the important words are "where appropriate". Who decides whether the centres are appropriate? That is a major issue.
	The motion includes three issues with which we disagree. First, it refers to the report from the College of Emergency Medicine, which is a new organisation, in its first year. We welcome its report and hope that it prospers, but we disagree with the suggestion that the clinical case for urgent care centres is unproven.
	Secondly, the motion refers to the
	"lack of evidence to support models which are centred on financial concerns and pressures arising from the European Working Time Directive".
	Thirdly, it refers to a lack of urgency in addressing concerns about trauma care.
	There are a couple of neutral issues. We believe that the public should be given a more meaningful voice about the provision of local emergency services. We may disagree about the way in which that is done, and we do not agree that there has been delay in the urgent care strategy. I can understand, given the report that was produced two years ago— [Interruption.] I will deal with that shortly.
	We want to hold a genuine debate about the motion and the amendment. As I said, I, like all Labour Members, wholeheartedly join the hon. Member for South Cambridgeshire in acknowledging the excellent reputation of emergency and urgent care services in this country, and the dedication and commitment of NHS staff to providing an outstanding service to patients 24 hours a day, 365 days a year. I hope that he will join me in acknowledging the support that the Government have given the NHS: massive investment; doubling the number of emergency consultants; an increase of 135 per cent. in funding for ambulance services, and greater numbers of people in training, which leads to better, faster treatment, with greater patient satisfaction.
	I hope that Opposition Members also recognise the steps that we have taken to improve the pay and conditions of staff in our emergency services. The hon. Member for South Cambridgeshire has suggested a day of celebration of nursing in this country. Given the plans of the shadow Chancellor and the Leader of the Opposition, that day might merge with the day when everyone looks back on when they had defined benefit pension contributions, because, as I understand it, while applauding the work of the 1.3 million people in the NHS, Opposition Members are also keen to attack their pensions.

Alan Johnson: Ah! Well, that is very interesting.
	As well as improving pay for staff on the lowest pay grades, "Agenda for Change", which was introduced in October 2004, has significantly improved the pay and conditions for ambulance staff in particular. They are no longer expected to work nights, weekends and public holidays for the same rates of pay as normal hours. Their pay has increased, as has the training and the professional development that they receive.
	The hon. Member for South Cambridgeshire is right that winter pressures place additional strain on urgent and emergency care. As hon. Members will know, last month was the coldest December for 30 years. Increases in accidents, flu cases and other health problems associated with cold weather put the NHS under great pressure. In some hospitals that I visited, it was miraculous that the staff were keeping the service going at such high level of quality. At one hospital that I visited in Yorkshire, the amount of ice on the roads meant that it had to treat 200 fractures over four days. However, better planning, more staff and improved organisation have given the NHS the capacity to cope with such pressure without a return to the dreadful scenes of the early 1990s, when many A and E departments had to close because they could not cope with patient demand.
	I agree that we should support further improvements of acute hospitals and develop more specialist centres. I would also like to point out that the abolition of long waits and greater investment in specialist centres for conditions such as stroke over the past 12 years has radically transformed patient care in our hospitals. I, too, welcome the report by the College of Emergency Medicine, but I take issue with the claim that the vital reconfigurations of urgent and emergency care services are motivated by financial constraints or that they are clinically unproven. Every reconfiguration of urgent and emergency care is clinically reviewed by the national clinical director for urgent and emergency care and his team. All decisions are taken on the basis that they will improve patient safety and improve the quality of care and that they balance these concerns against improving patient access.

Alan Johnson: We all accepted when we came into power in 1997 that the three major killers—cancer, heart disease and stroke—needed to be tackled. They could not all be tackled at the same time and with the same intensity. However, it is fair to say that although we saw early improvements in cardiovascular disease and cancer in particular, stroke care came a little later. The hon. Gentleman is right to say that. I do not know when the Stroke Association said the words that he quoted, but it has worked closely with us to improve services. Neither we nor the Stroke Association believe that we have a perfect stroke care service. However, in relation to the very issues that we are discussing today, we do believe that as specialist centres are introduced more widely and as we put in more resources and implement the stroke strategy, outcomes will improve accordingly.
	I was talking about how we deal with reconfigurations and what the Conservative motion says about the importance of concentrating services where appropriate. As part of his review last year, albeit that it was separated from the final publication by a couple of months, my noble Friend Lord Darzi set out clearly the rules that will govern the changes. I would be very surprised if there were any differences, given the importance that we all attach to moving with the times and implementing more specialist care. Lord Darzi said that change must
	"always be to the benefit of patients,"
	and that it must always be "clinically driven". Change must not come from a Richmond House edict, but must always be "locally-led,"
	"Meeting the challenge of being a universal service,"
	and recognising that
	"Different places have different...needs".
	Change must always involve patients, the public and local staff. If proposals are adopted and change is to occur, the local population has to see the benefits in place first, before the changes occur. That means some quite expensive but very necessary double running to ensure that things work. That seems to be the perfect model in a world where no one is suggesting—I presume that that includes those on the Opposition Front Bench—that there must be no change and no so-called reconfigurations whatever.
	Professionals estimate that between 50 and 70 per cent. of people who turn up at A and E would be better treated elsewhere. The majority would be better treated in primary care—that is why primary capacity is so important, as my hon. Friends have rightly pointed out—or in minor injuries units or urgent care centres. Our urgent and emergency care services see patients with a huge range of conditions, from a major trauma to a broken finger. It is nonsense to suggest that a patient who has twisted an ankle is always best accommodated alongside a patient who has had a heart attack or been seriously injured in a road accident. To deal with major trauma or severe injury successfully, A and E departments need the right concentration of expert staff to assess critically ill patients quickly. In many areas, there will be two A and E departments in relatively close proximity to each other, trying to do that as well as deal with many less serious complaints. That is why many SHAs are taking decisions to concentrate expert A and E staff in one hospital and equip the other to deal with more minor complaints. That is what has happened successfully in areas right across the country. The suggestion that these decisions are being taken because of the European working time directive is, frankly, laughable.

Alan Johnson: The social chapter—the hon. Gentleman is right to correct me, as the social contract is something completely different, which I well remember from the early '70s. Let us be clear: the Tories got confused about the social chapter and the British taxpayer— [Interruption.] I am asked what this has got to do with it, but the European working time directive is mentioned in the motion. They got confused and spent thousands of millions of taxpayers' money, fighting a case in the European courts, which they lost because it is a health and safety measure and does not come under the social chapter or the social contract.
	I was also asked in an earlier intervention about the opt-out, which the British Government intend to maintain. In co-decision with the European Parliament, we will maintain the opt-out as we have done for 12 years. The fact is that that argument—Opposition Members should understand this—will make not the slightest difference to the NHS. There is a separate agreement for junior doctors. We have decided—I would be surprised if anyone took a different view—that the national health service will have a 48-hour working week with no opt-out. The reason for that is that with the rotas and flexibility necessary in the NHS, the system cannot be run effectively if we are constantly depending on who opts in or out. Whereas individual doctors can, we are implementing this by having a 48-hour week, which will come about on 1 August 2009.
	That is not to say that we do not recognise the argument about doctors flogging themselves to death. The hon. Member for Banbury (Tony Baldry), who is no longer in his place, raised this issue and said that he is kept awake at night worrying about the working time directive. The point of that directive was to stop clinicians staying awake all night because they were obliged to be at work for horrendously long hours, which adversely affected the quality of care provided.

Andrew Lansley: The Secretary of State lectures us about the working time directive, but ignores the point that really matters. There was an agreement in the Council of Ministers to change the definition of "resident on call" so that it related to time spent actually working at night rather than all the time when one is resident but asleep. That is a critical issue, so will the Secretary of State explain why Labour Members of the European Parliament voted against the Council of Ministers' compromise, the purpose of which was to enable us to interpret resident on call in a way that worked for the national health service?

Alan Johnson: I apologise for encouraging them, Madam Deputy Speaker.
	The hon. Member for South Cambridgeshire is wrong to say that we are not prioritising the improvement of trauma care. We believe trauma care needs to be recognised as a specialist form of medicine. Patients who are severely and critically injured need the expertise of many specialist professionals—from critical care doctors to neuro-surgeons. Just as we have improved specialist care for conditions such as stroke, so we will also improve trauma care. That is why, as part of my noble friend Lord Darzi's review of the NHS, every strategic health authority set out how they would improve the provision of trauma care—most by setting up specialist centres in trauma care.
	The hon. Member for South Cambridgeshire asked in his speech and his motion what happened to the report and why there was nothing in the Darzi review, save for the three-digit number, about urgent care. What he fails to recognise is that the Darzi report incorporated all nine SHAs' visions for the future in their regions, which were worked out with their clinicians, their patient groups and the public. The final report published in July last year was an implementing document or an overview so that all of that could be put in place.

Alan Johnson: I do not think that the process should be judged by the profession of the person chairing it. Someone has to chair these groups and in this case it was necessary to look at clinical services right across the patch. The point is that trauma was a priority in every SHA report. They made it a priority in the regions. People cannot accuse us of being top-down and top-heavy and tell us we should have local involvement, and then complain when the Darzi review is implemented in that very way—I am not saying the hon. Member for Romsey (Sandra Gidley) was complaining, but Conservative Members were.
	The report on trauma care was published two years ago just as the Darzi review was being formulated, and the idea now is to carry forward those visions in each strategic health authority. We need someone to oversee this, however, and I can today announce that I am appointing Professor Keith Willett, chair of the British Orthopaedic Association's trauma committee and a leading international expert on fractures and trauma, to be the first national clinical director for trauma. The hon. Member for Banbury, who is not in his place, will probably know him very well because he is a leading clinician at John Radcliffe, Oxford.
	I agree that the public should be given a say in how urgent and emergency care services are configured. Indeed, the next stage review sought the views of more than 40,000 people, and asked them specifically what improvements they wanted to see in urgent and emergency care. Clinicians used the views expressed by patients to make their recommendations for what should happen in each region.
	I join the hon. Member for South Cambridgeshire in his praise for the contribution made by community first responders. They play a vital role in improving responses to 999 calls in many parts of the country and in supporting ambulance services. They are not, however, a substitute for an emergency ambulance response. I am delighted that the Opposition are favourably disposed to potential plans to bring in a new, single digit number to access urgent and emergency care services. As my noble friend Lord Darzi has pointed out, this would provide a quick, convenient way for people to find out about local urgent care services, particularly out of hours or away from home, and we will be consulting on this proposal in due course.

Sandra Gidley: I welcome this debate. When I first read the Conservative motion, I thought it was a bit of a hotch-potch: half of it nobody could disagree with—it praises everyone under the sun, and there is nothing wrong in that—but the rest of it seemed like the product of a brainstorm, with references to almost anything that might be remotely related to emergency and urgent care. However, although some of those topics have not been pursued in the debate so far, the Conservatives have highlighted a very important subject.
	The hon. Member for South Cambridgeshire (Mr. Lansley) took the Secretary of State to task for amending the motion to mention out-of-hours care, but I think the changes in the provision of that care have had an impact on emergency and urgent care, so it is probably worth mentioning some of them. The Government have done many things to improve care for patients, but they would probably acknowledge quietly that one of their biggest mistakes was to take responsibility for out-of-hours care away from GPs and put it in the hands of the primary care trusts. As a result, the GPs were only responsible for the core hours from Monday to Friday. In some areas, GPs wanted to provide weekend care, particularly if they had a high commuter base, but that was actively discouraged by PCTs. The costs shot through the roof, and in some places the out-of-hours services were introduced hurriedly—to describe what was on offer in many areas of the country as an "unmitigated disaster" is putting it quite mildly. Many people waited more than four hours for a GP to arrive. In my area, we are flying in doctors from various parts of the European Union. A lot of them are German. I have no problem with German doctors; they are all very nice, and people generally had a positive experience. However, those doctors did not understand local services and a number of significant problems arose; if they wanted to section somebody, for example, they did not understand the UK law and procedures governing that decision.
	The number of people resorting to calling an ambulance also markedly increased. It is perfectly understandable that a concerned patient might do that if the out-of-hours service is not responding and they are not getting the reassurance they need. We should not criticise patients for doing that.
	The Government amendment applauds the increase in GP opening hours. I concede that that may have enhanced choice, but I do not think it has improved access to urgent care because many people are making routine appointments for those extra hours. It is important to consider what urgent care actually is, and it is worth posing a couple of fundamental questions. How does the patient know whether their symptoms are the sign of something serious—whether they can wait to have them checked out, or if they should be making a fuss about being seen? It is clear that different patients respond in different ways. Most GPs will have their regular complainers, but in the days when GPs knew their patients—I hate to say "the good old days", because I am not sure they were good in all respects—the GP was often able to make a value judgment. They could say, "I saw Mrs. X only last week. I know her quite well, and I think reassurance will go a long way in this case." In the hands of a doctor who does not understand Mrs. X, however, more resources might be used because they do not know the background and personality of the patient and they will therefore treat them on a more precautionary basis.
	I suspect that most Members present will have been out with an on-duty ambulance crew. From witnessing them calling on people, it is obvious that there is a wide range of differing attitudes as to the circumstances in which it is appropriate to call the ambulance service out. One of my first pieces of casework when elected as an MP related to an ambulance that did not arrive to a call from a rural setting, and I was horrified to find out that ambulance crews were often having to deal with very trivial cases. Although the ambulance service does a wonderful job, it does not need to do much of what it does. Every time somebody with a trivial complaint calls out an ambulance, they are potentially endangering the life of somebody else. That risk is not communicated often enough.
	The first point of call for people who are ill is usually the surgery. Even if it is closed, they often think of calling their GP, and, in many cases, the call is diverted to the appropriate out-of-hours service. That is what one would expect, but the recent Healthcare Commission report showed that in a significant number of cases—I cannot recall the statistic off the top of my head—the relevant information was not communicated. That resulted in the patient either having to dial somewhere else or thinking that they did not want to speak to a doctor who they did not know and wondering whether they had any other options. Some people will look at various websites for advice, whereas others will go to their nearest pharmacy. Accessing NHS Direct, either on the web or by phone, is a popular choice. Other people will choose to use a walk-in centre or out-of-hours care, or they may call an ambulance because they do not know what to do and are worried.
	I welcome the move towards having a single contact number, but I make a plea that during the consultation we examine what has happened when the police and other bodies have introduced such a number. Often, what has happened is that all the other numbers have gradually been withdrawn and people have not then been able to choose to ring the department that they want directly; they have always then had to go through a central switchboard, and often they have not been able to ring their local provider and speak to the person whom they know. To be fair to the police, locally they have got much more sophisticated about this and have found other ways of getting around the system. People who know who they wish to ring find it frustrating to have to go through a bureaucratic telephone triage service—to go somewhere else. By all means, let us have a single point of contact, but if someone knows who they want to contact, it should be easy for them to do so—there should be no barrier. So, there are pluses and minuses to the proposal.
	I wish to discuss the strain on ambulance services. As a result of inappropriate calls, the London ambulance service, among others, introduced a clinical telephone advice team to advise callers who had less serious conditions—the team made a point of ringing such people back. During 2007-08, the London team handled more than 58,000 calls, and analysis showed that, over the year, that freed-up the equivalent of 35,383 ambulances for patients who needed them more. Not every ambulance trust has that sort of system in place, despite facing similar pressures, so it may be worth considering whether that is best practice. Although different areas rightly provide different solutions, it is also worth examining things that work well elsewhere.
	This might be an appropriate time briefly to mention ambulance response times. The most commonly known target is to reach 75 per cent. of category A life-threatening situations within eight minutes of the call. I have never been able to establish why eight minutes was decided as the crucial figure or why 75 per cent. is acceptable—perhaps the Secretary of State could enlighten me—but there are added pressures this year. In previous years, some ambulance trusts have been accused, rightly or wrongly, of manipulating the time when the clock started in order to improve their results. Now, so that there is no dispute, the clock starts ticking as soon as the call connects and, thus, there is a level playing field.

Sandra Gidley: This could be a debate that we have had in Westminster Hall, but as some hon. Members were not present for that, it is worth repeating things. In addition, some of the points from the Westminster Hall debate were not addressed. If the hon. Gentleman is saying that because we had a debate on Equitable Life, we do not need to discuss it again, that is fine, but I contend that if a subject is important, it is worth discussing on repeated occasions.
	Prior to the meeting with my constituent, I had no inkling of the fact that if I were seriously injured in a road accident, my prognosis would be severely affected by whether or not a voluntary doctor was available. Many such doctors work full-time in the NHS, often in disciplines such as anaesthetics and sometimes in emergency care. I had always thought it was like "Casualty"—once a year, usually on the Christmas special, there is a major incident and all the casualty doctors go to the scene of the accident—but, in real life, that is not what happens in most parts of the country. This matter is important because of what is said in the often-overlooked 2007 report by the National Confidential Enquiry into Patient Outcome and Death, entitled "Trauma, Who Cares?". It concluded that the current structure of pre-hospital management is insufficient to meet the needs of severely injured patients. There is a high incidence of failed intubation and of people arriving at hospital with a partially or completely obstructed airway. The report continued:
	"Change is urgently required to provide a system that reliably provides a clear airway with good oxygenation and control of ventilation. This may be through the provision of personnel with the ability to provide anaesthesia and intubation in the prehospital phase, or the use of alternative airway devices."
	The report said that ambulance trusts must address that.
	The stark reality is that patients who die from severe injuries often do so within the first hour after an accident, and in the UK that time has usually passed before the patient reaches hospital, and that is on the assumption that the ambulance and paramedic response to the scene is normal. If a BASICS doctor arrives, they can stabilise the patient at the scene of the accident and decide the most appropriate destination for that person. It must be borne in mind that, because of centralisation of services and major trauma centres, the destination is not always the nearest hospital. BASICS doctors therefore provide a benefit in terms of the appropriate care.
	During the Westminster Hall debate, the Minister said that he would shortly have a meeting with the people responsible for producing the report from National Confidential Enquiry into Patient Outcome and Death, and that he would raise some of the issues that were mentioned during the debate. It would be useful if he could update us on that. The BASICS service is voluntary and often funds its own equipment because doctors do not have enough time, after doing their full 48 hours in the NHS, to provide the emergency service and carry out fundraising.
	Some parts of the country, such as Sunderland, have focused on trauma injuries and significantly reduced the death rate from major trauma from the national average of 5.8 per cent. to 2.9 per cent., and have introduced new response teams, which seem to be having an effect.
	Many parts of the country rely on air ambulances, and it is frustrating that the running costs are often funded by local donations and voluntary contributions. I am a little worried about that because, although in my neck of the woods in Hampshire the air ambulance service is relatively new and is well supported at the moment, there is concern that funding for all charities may decline, given the current financial pressures. The South Central Ambulance Service NHS Trust told me that it pays for the clinical response, but not for the helicopter, which is funded by a well organised group. That was a strange response, because it does not say that it will provide paramedics but not fund the costs of ordinary ambulances. I am not sure of the significance of different modes of transport. What consideration has the Minister given to charitable funding of air ambulances, and does he believe that that is sustainable in the long term?
	Last year, the Healthcare Commission's report, "Not just a matter of time", reviewed urgent and emergency care. It concluded that most sectors performed well against national standards for access to services, but it found that performance was more varied in services that receive less national attention. That is no great surprise, and Members of Parliament are always highlighting those services. The overall stats show that the response to category A calls was generally good. That is where the main focus falls, and there is not a lot of room for argument, but one should note that those results are given by trust. I made a freedom of information request to find out the response times on a ward by ward basis in my constituency. Lo and behold, those parts of my constituency in Southampton received an 80 or 85 per cent. response, which is excellent for people who live in the big city, but in some of my more rural wards an ambulance had never reached an emergency within eight minutes. That is not something to shout about, because it is inequitable—indeed, it is the reverse of the inequality usually seen in the health service, because those who are suffering are not those who live in urban areas, but who perhaps live in more affluent areas. Does the Minister have any plans to refine the targets so that it is realistic to expect an ambulance to reach people within eight minutes, wherever they live, not just in the large urban conurbations?

Simon Burns: May I try again on the targets? Despite the look on the hon. Lady's face, I think that she misunderstood my point. She suggested that the eight minutes starts at the moment the call is taken, but if someone is agitated they may take three minutes to explain why they need an ambulance, and someone who is less agitated or more articulate may take 30 seconds. Surely a target of eight minutes is unfair if the starting time for monitoring purposes is the moment that the call starts. That is all I was trying to say.

Sandra Gidley: If the hon. Gentleman does have a quick and easy answer, it is probably not appropriate for an intervention. He might want to stand up and make some comments later, but I feel that I should finish my speech so that other hon. Members can speak.
	The response to category A calls is good, but there is much more variation between the targets and the responses in the case of other urgent calls. The Healthcare Commission found that in some areas fewer than 80 per cent. of ambulances arrive within the target time. On arrival in hospital, there are significant variations in the proportion of patients seen by a doctor or nurse within the first hour after arrival. That figure varied from 40 per cent. to 100 per cent. Clearly, there is work to be done.
	There is also evidence of poor compliance with guidance on access to medication from out-of-hours GP services. Although that might not be seen as urgent care, if a patient is in pain or something like that, the care is certainly urgent to them. Concerns were also raised that suggested that many people were either unaware of the full range of urgent and emergency care services or were unsure about how and when to use them, which brings us back to the issue of the single contact number. Most importantly, the need to improve the way in which the services work together was highlighted.
	Data sharing is poor and PCT commissioning was highlighted as a concern. A survey produced last week showed that patients rate their care highly but raise concerns about pain control and information given on discharge. That takes us back to the mention of data sharing in the earlier reports. The people who are providing emergency care often do not have sufficient information about the patient. If somebody has been in accident and emergency, or has even been treated in out-of-hours care services, the relevant information is not always relayed back to the GP in as timely a fashion as it could be. Perhaps the Minister could tell us when decisions will be made about information sharing with regard to the NHS IT project. There is a lot of healthy debate about what level of information can be accessed by whom, but it could be crucial to outcomes in those particular cases.
	I want to end by making a comment that many hon. Members start their speeches with: I thank those who do their best to provide an emergency service, whether they are paid workers or volunteers such as community first responders or BASICS doctors. We owe it to all those people to ensure that attention is given to ensuring that people have the best possible outcome in the case of emergencies and that the PCTs ensure that funding streams are adequate. The problem with this area of medicine is that most people are grateful to have received urgent care, and they are often so pleased to be better and to have their problems sorted that they do not take the time to step back and ask whether their outcome could have been improved or whether their quality of life could have been different had a doctor been on the scene. Staff want to do better, but in many cases they are hampered by a lack of attention to best practice and, in some cases, sadly, by a lack of funding.

Joan Ryan: I will not, because I have only 15 minutes. I am sorry that I cannot give way, but time is pressing.
	I want to go back a little to the remark made by the hon. Member for South Cambridgeshire (Mr. Lansley) that we should stick in this century. I would like to point out that we are only nine years into this century, which is not a lot. The idea that history has no impact on the present or future is clearly nonsense.
	In 1997, when I was elected MP for Enfield, North, through the doors of my advice surgery came many people, often elderly people, who had waited almost two years for a hip replacement. They had waited in pain. That pain not only made the quality of their lives appalling but, even after the operation, undermined their health. Lots of people came to my surgery who had waited considerable amounts of time for cataract removal. The wait significantly affected their ability to engage in life and to be independent. I no longer have anybody coming through my surgery doors with those problems. That is not to say that nobody comes through the door with issues about the NHS, but they do not come to see me with those problems. The 18-week wait is a significant gain for the people of this country who depend on the NHS.
	All those factors affect urgent and emergency care. If people are dealt with early in the onset of any illness or disease, they are much more likely to make a good recovery and much less likely to present at an emergency department at some point in the future. The same is true if there is good, accessible, available primary care, as people are then much less likely to need to present at an accident and emergency department or to need urgent care.
	In Enfield, we very much need the primary care strategy that our primary care trust is planning. I worry that the Conservative policy of deriding and undermining confidence in the notion of a polyclinic will damage the ability to put in place a good primary care strategy. Let me give an example of what that strategy means to us in Enfield. We know now that we are getting a health centre in the Enfield Lock area. Professor Sir George Alberti came to Enfield, and he said, "You need an improvement in access to primary care in the north-east of your constituency." That is now happening. The plan is that we are to have a big health centre with an independent living facility attached to a community school. It will provide a first-class service to the people of Enfield Lock, Enfield Highway and north-east Enfield. That will reduce the number of people who have to leave the area and go to accident and emergency centres with problems that local GPs or walk-in centres can deal with. The health centre will mean that people have much more access to local primary care.
	The primary care strategy will have another impact in Enfield, North. Although it will not be built in the next two or three years, a polyclinic is planned for the town centre. Many GPs practise in that area, so it is nonsense to say that people will have to travel vast distances to get to their doctor if a polyclinic is set up. It is a densely populated, town-centre area, so there is no need to fear that. The polyclinic will have longer opening hours, and people will have much greater access to a greater range of specialist GPs. Moreover, the centre's technological diagnostic resources will mean that people will not have to wait for a hospital appointment to get the same service.
	The primary care strategy for Enfield, North means that there will be a polyclinic in the town centre and a health centre in north-east Enfield. Add to that the fact that people will have access to the Forest road health centre just over the border in Edmonton and to the walk-in centre at the North Middlesex hospital, and it is clear that the strategy will be a huge improvement.
	The result will be that people will have access to their local health centre and then, if they need it, they will be able to go to the much larger health centre set-up that is sometimes known as a polyclinic. Beyond that, they will have the walk-in centres, local accident and emergency facilities, and the trauma centre provided by the North Middlesex hospital. At local level, the primary care strategy will really serve the needs of people living in Enfield. I worry that some of the propaganda pumped out by the Opposition encourages people to fear any kind of change at all. It undermines their confidence in the excellent service provided by the NHS, and in what is very necessary change to primary care provision.
	I want to say a few words about Chase Farm hospital. I am pleased to have the opportunity to do so as I have spoken about it many times, both in this Chamber and in Westminster Hall. Indeed, the hon. Member for Enfield, Southgate (Mr. Burrowes) had an Adjournment debate on the issue only last week. I attended and intervened, and my hon. Friend the Minister is well aware of my views.
	I do not oppose change, but it is important that local people are listened to and, without exception, the people and elected representatives in my constituency do not support the proposed changes at Chase Farm hospital. However, that needs to be put in context, and to that end the past is important once again. For the first time in 20 years, the people in my area can be confident that a hospital will be maintained on the Chase Farm site. We have managed to achieve some real gains, including ensuring a secure future for the hospital, and I advise anyone who doubts that—including Opposition Members—to compare local Conservative literature with the hospital trust's original proposals. One of those proposals was to close the hospital altogether, so it is clear that our success in saving it is a real achievement.
	The second gain is that there will be an expansion in planned surgery at Chase Farm hospital. That protects the heart of the hospital—its wards and operating theatres—and so is very important to people in Enfield, especially those elderly people who are much more likely to need orthopaedic and other operations. It is very important that they be able to go into hospital locally.
	We have also gained some local accident and emergency services. The original proposals put forward what might be called a "hot-cold" model, under which Chase Farm would provide only elective—that is, planned—surgery and nothing else. We have managed to get rid of that proposal, which is a gain in itself. In addition, and with the support of the Minister, we have also managed to achieve agreement about having a midwife-led birthing unit, so that Enfield babies can continue to be born at Chase Farm.
	I am not in favour of any reduction of service at Chase Farm hospital, but it is important to understand the context. I shall continue to campaign and do everything that I can to maintain the present level of service.
	The motion refers to a report from the College of Emergency Medicine, but the interpretation offered by the hon. Member for South Cambridgeshire was inaccurate. In an intervention, he spoke about distances, but in that respect the report does not help the argument about Chase Farm hospital. I have asked the Minister to look at the matter again, given the significant increases in birth rate and the elderly population. The report notes:
	"There is no single solution to the reorganisation of emergency care. In urban areas where"
	emergency departments
	"are close together (less than 10 km apart) there may be advantages to amalgamating services".
	That would not help our argument, as Chase Farm hospital is 9.43 km from North Middlesex hospital, and 10.48 km from Barnet hospital. Therefore, the report does not make the across-the-board point that the hon. Gentleman imagines. It might be more applicable in rural areas, but I do not know, as I do not represent a rural area. It certainly has very little application in my area.
	The report says that each case must be taken on its merits. I agree: I have presented the case for Chase Farm hospital and will continue to do so, but I will not accept that the NHS is almost no better than it was in 1997, as it has improved significantly. There has been a huge step change, and it is time that people gave that more credit, rather than always talking the service down and looking for the negative.

Simon Burns: I am delighted that we have the opportunity today to debate emergency and urgent care in the NHS. I fully support the motion put down by my right hon. Friend the Leader of the Opposition and our Front-Bench team, but—perhaps unusually—I can also support the beginning of the Government's amendment.
	Like my hon. Friend the Member for South Cambridgeshire (Mr. Lansley)—to be fair, I must add that the Secretary of State expressed the same sentiments in his opening remarks—I fully support and admire the people who work in the NHS. Without all the doctors, nurses, consultants and ancillary workers—who too often are not mentioned—we would not have a national health service. They are there, day in and day out, often without much praise or notice, delivering health care to our constituents and to ourselves.
	In my brief comments I shall discuss accident and emergency services, which all too often work under tremendous stress and strain. For many members of the population, that is the first point of contact with the local hospital. The problems that A and E services face have been exacerbated—certainly in my area, mid-Essex—by the dramatic increase in the number of people turning up or being admitted to A and E as a result of drug or alcohol-related abuse. That is a growing problem.
	The Minister of State, Department of Health, the hon. Member for Exeter (Mr. Bradshaw), who is on the Front Bench now, answered a written question from me yesterday. His reply showed that in 2002-03 there were just over 2,500 admissions to Broomfield hospital in Chelmsford as a result of drug or alcohol-related problems. By 2005-06 that had increased to just over 4,000 episodes. Fortunately, the next year, 2006-07—the last year for which figures are available—the level had marginally dropped to just under 4,000, but the figures show the dramatic increase in that problem, arising from the increased incidence of binge drinking and irresponsible drinking and behaviour in our town centres. The problem is spreading to our rural areas as a result of abuse, a misunderstanding of the dangers of alcohol consumption, and the failure to adopt a responsible and mature attitude towards it.
	The knock-on effect is the strain that that puts on A and E staff, not only because of the medical problems emanating from the abuse that brings people to A and E, but sadly, because of the behaviour of some of the patients resulting from the state of mind that they are in. If someone has been brought into A and E by friends who have been out with them, the friends, too, may be suffering the effects of alcohol abuse, which exacerbates the problem and the way in which they interrelate with staff. The patience and the behaviour of such people are not as they would be if they were sober. That is unacceptable and needs to be addressed more strenuously than it is at present, although I accept that most hospitals are adopting zero tolerance of bad and antisocial behaviour.
	A similar problem, although it does not arise directly from alcohol abuse, is violent and aggressive behaviour towards staff. It is incredible that people whose entire raison d'être and work is to relieve pain, remedy sickness and reduce the suffering that results from illness should be verbally or physically abused for their pains. It is a sad reflection of the society in which we live.

Nicholas Soames: Will my hon. Friend confirm that the increased workload comes on top of substantial increases in the workload caused by respiratory infections in elderly people, flu and the norovirus, which have placed an immense added responsibility on accident and emergency departments? By and large they have coped magnificently.

Simon Burns: My hon. Friend is right. He highlights another problem that has developed in the health service. It was always assumed that the pressure points of increased activity occurred in the winter months when it was coldest or iciest. In the past few years we have seen that those pressure points in the NHS are no longer restricted to the traditional winter months when the weather is particularly bad. In my local hospital, Broomfield, the pressure was worse in June last year than it had been in the worst winter month. The health service has had to adapt to changing circumstances, and the old accepted problems of winter pressures are being extended, for other reasons, to other months, putting extra pressure on resources and staff.
	There is a further issue facing accident and emergency services which it might not be tactful to discuss. The NHS must be tough and not only accept that there is a problem, but be brave enough to try to do something about it. Sadly, part of the population go to accident and emergency for treatment as a first resort, when their complaint is in no way related to an accident or emergency. A and E should not be their first port of call. They should use NHS Direct or contact their GP or, in some cases, their pharmacist. If people misdiagnose themselves and misdirect themselves to A and E for treatment, that puts excessive demands on the health service and on other patients waiting for A and E treatment, who may have far more serious complaints or conditions that warrant their being there in the first place. More must be done to educate people and to explain why they should not trot along to A and E simply because it is more convenient for them.
	On the four-hour waiting time limit, four hours may be a relatively short time compared to the length of time that some people had to wait in the past, but it is still quite a long time to hang around waiting. For someone who goes to A and E with a medical complaint that is acutely painful, even if it is not as medically serious as the pain that the individual is suffering, four hours can seem a very long time. My A and E at Broomfield reflects the situation nationally. We have seen a significant increase in the number of people attending A and E in recent years. In the year up to December 2007 there were 5,469 attendances at A and E. The next year, ending December 2008, the figure was up to 5,783. The target that 98 per cent. of people should wait less than four hours is being met in my A and E department. The latest figures for 2007-08 show that it achieved 98.3 per cent. I accept that that is of little comfort to the 1.7 per cent. who are not included in those figures.

Simon Burns: Absolutely. I wrote to the Minister only yesterday because I have been sent a series of allegations about what happens in A and E, and I would be grateful if he would look into them.
	The point is that we must move forwards. We must ensure that there are improvements so that patients not only receive the best treatment possible, which I have no doubt that they do get at my hospital, but that the waiting time is short and the triage is swift, and that they are dealt with sympathetically and treated as quickly as possible. I welcome the fact that, as a result of the Healthcare Commission survey and the trust itself examining what goes on and what should and must be done to improve the situation, the trust has been prepared to recognise that improvements need to be made and is taking initiatives.
	For example, by the end of next month a major refurbishment of the physical site of the A and E will have been completed—an important and positive step forward. On some days a GP now works alongside the A and E team to help with patients with minor injuries and ensure that they are referred to the relevant professionals. New shift patterns have been introduced for the nursing staff to seek improvements, and a new triage system has been introduced to identify major and minor patients and ensure that they are treated more quickly within the department. A fourth A and E consultant has been recruited, and a new general manager has been appointed to oversee the work of that department.
	I welcome all those initiatives. They are a positive step forward. I have no doubt that we can work together with the sole aim of improving the quality of care and the quality of the experience that patients have at A and E. Most of them are not there for the wrong reasons, but because they are in pain and probably frightened or confused because they do not know what is wrong with them, and need assistance. That is why it is so important that we ensure that we have an A and E service in our local communities that is second to none, and meets the requirements of all of our constituents.

Nadine Dorries: I come to this debate with a range of experience of accident and emergency units. I was working in the A and E unit of Royal Liverpool university hospital on the night of the Toxteth riots; we admitted just over 350 people that night. I therefore have experience of acute care at its most acute. I have also worked in a minor injuries unit in the same region. The unit was a new development in the area and it came about as a reconfiguration. However, it was not led by Government or driven from Whitehall—it was designed locally by the local hospital trust and local people.
	The minor injuries unit worked well. Everybody in the area knew what they should go to the unit for and what they should go to the accident and emergency department for. The unit dealt only with minor injuries; we sutured, X-rayed and dealt with basic fractures. The local community knew that, because the unit had been established following local consultation, including GP-patient groups. What was designed and established was what the local community needed, so the community blended well into that provision and used it well.
	The Secretary of State said that one of the prerequisites that Darzi had mentioned was that services should be "locally led", but he endorsed what the Government are doing by using the words of the national clinical director of emergency care, who did not mention consultation or interaction with local communities, patient groups or GP-patient groups. It feels as though the reconfiguration is being driven by Whitehall rather than by patients, users, doctors or nurses.
	Would the same overall blanket approach work with polyclinics? That approach is being taken with them and although I do not disapprove of polyclinics in principle, I believe that local communities have local needs and that polyclinics would work in some areas but would not work at all in others.
	Some of our patients in the Royal Liverpool university hospital on the night of the Toxteth riots came through our doors in shopping trolleys. I will not forget the scene of almost carnage outside the A and E doors as I left after a 12-and-a-half-hour night shift; I do not think that the working time directive would have worked very well in that instance. I do not even know from where we drafted some of the people who worked on the unit that night; we dragged members of staff from all the wards.
	The one thing that I know about working on A and E is how the relationships, expertise, knowledge, and trust and respect for colleagues build up over time. Such departments are unlike any other in a hospital, perhaps because they get the blue-light jobs and the cases that they deal with are frequently matters of life and death, or perhaps the explanation is the high level of expertise deployed and the high level of training needed by both the nurses and doctors. The departments that interact with A and E—physiotherapy, radiography—all link in as well. There is a high level of skill in A and E departments, and it builds up not only through training but through the other staff.
	I am concerned that we are losing those skills because of some of the targets, because of the reconfiguration that is taking place and because of the loss of morale and disenchantment among some staff. Last week, I spoke to two nurses who are now working in GP practice having worked at Bedford hospital and at Luton and Dunstable hospital. Both had left A and E as a result of centrally imposed targets. One of them said that she decided that the time to leave was when she put the phone down after she had been told that she absolutely must admit a patient from an ambulance that had been parked outside with a patient inside for some time in order not to contravene the target once the patient came in through the doors. If she had acceded to that call and admitted the patient, she would have seriously comprised the quality of care that was being provided in the unit, given the short number of staff she had on duty on that day. She was left with the option of transferring staff quickly out of the A and E department into inappropriate wards that also did not have the correct number of staff with the appropriate training, skills or ability to look after the patients who were in A and E at that moment.
	The nurse was dealing with a road traffic accident, or RTA. In my day, almost everyone involved in an RTA ended up in hospital, but because of the safety requirements for most cars today only the very serious cases end up there. If somebody does require serious treatment they are usually very ill, and if there is not a trauma unit nearby they will end up in A and E. The nurse had some very seriously injured patients in her A and E department as the result of an RTA, and while she was trying to care for her patients she was being harassed to take in other patients to meet a target. That was the day when she decided to walk, and we lost an absolutely superb, well trained nurse manager from an A and E department who had worked there for 12 years and built up an incredible level of expertise. The nurse from Luton and Dunstable hospital had done exactly the same thing. The figures show that we are losing nurses from A and E departments all over the country because of the targets that are being imposed.
	No mention has been made of the patients who have to loiter outside A and E departments in ambulances or how that impacts on ambulance crews. The hon. Member for Romsey (Sandra Gidley) talked about the waiting times from when the call is received to the ambulance getting to the patient, which are longer in rural areas. It is increasingly difficult to get ambulances to respond in the time that we need when they are still parked outside A and E doors because their patients cannot get through the doors because they might contravene a target that has been imposed on A and E staff. If the Government were going to start configuring A and E services, they should have looked at some of the existing fundamental problems before they started to look at how they farm out the entire service.
	Minor injuries units, like polyclinics, can work well where there is a community need, but that need will not always be there. In fact, polyclinics can absorb much of what minor injuries units do. A minor injuries unit would probably be needed in an urban area with a high population density that is located a fair way away from a major hospital. Those are probably also the areas that would be better suited to a polyclinic, so it could be possible to deal with minor injuries at a polyclinic and combine the two things.
	The Royal College of Nursing agrees that the four-hour target is compromising the patient care being delivered in hospitals. That does not only apply to situations such as the major RTA that I mentioned. For example, instead of a patient who is in need of surgery, there may be a stroke patient who needs monitoring. Let me cite an example from my constituency. A patient who was 14 days post-delivery presented at her GP surgery with a hot calf, pains in the leg and breathlessness. She obviously had a pulmonary embolism and was sent to the A and E department. She was farmed out from that A and E department to the paediatric ward, but the right dosage of Heparin, which she needed to be given fairly quickly, was not available. The nurse therefore had to go back to the A and E department to get the correct dosage of Heparin and take it back to the patient. As a PE is a fairly serious condition, it would have been far better if she had stayed in the A and E department, been treated and monitored, and then taken to an appropriate ward when a bed was available so that she could be nursed properly, but unfortunately that did not happen.
	Like the right hon. Member for Enfield, North (Joan Ryan), who mentioned her granddaughter, I have experience of using A and E units not as a patient. Sadly, my own brother died in a unit where I was working at the age of 26, following a road traffic accident. He stood a chance when he arrived though our doors because he had been treated by a paramedic at the scene of the accident. Two dual-man ambulance teams arrived at the scene of his accident, and he was still alive when he arrived with us. One of the Government's proposals is to split the dual-man teams and revert to solo response teams. I am concerned about that. When a solo response team attends a serious accident, several things need to be done. Following a road traffic accident or a serious trauma, a patient will go into peripheral shutdown and will need to have a line put up pretty quickly. That is very difficult to do if there is not the correct level of assistance. It is hard to introduce a line in order to put in the intravenous drugs—the adrenaline and other things that will be needed to keep that patient stable until they get to an A and E department. One person cannot maintain a clear airway, administer drugs, deal with peripheral shutdown and insert a line if they are on their own or do not have the right level of expertise with them. It is not just about the clinical needs at the scene of the accident—they may have chaos around them, agitated and upset people, or more than one person requiring their help. If this move towards solo response teams becomes popular, patient care at the site of an accident will be compromised. I do not think for a moment that my brother would have got through the doors of the A and E if he had been treated by a solo response team.
	The Minister has claimed that the solo response team does not present a risk to patients and frees up resources for other calls. He said:
	"Fast-response vehicles can often get to the scene faster than traditional ambulances."—[ Official Report, 17 December 2007; Vol. 469, c. 1195W.]
	I am sure that they can, but I do not see why there cannot still be a dual-man team in the solo response vehicles. Why cannot there be two paramedics? Is the Minister referring to the fact that ambulances are larger or that they go more slowly? I am not sure why he is saying that solo response vehicles will get to the scene more quickly.  [ Interruption. ] The Minister is trying to indicate to me that a motorbike would be used. That is fine, but how would one man and a motorbike deal with peripheral shutdown? How would he maintain a clear airway at the same time? How would he administer drugs? How would he deal with the agitated and upset people at the scene? How would he deal with other people who may be injured at the scene? How could one person do all that? It is difficult enough for a dual-man team who are very pressurised and under a great deal of stress when they attend these scenes. How does one man on a motorbike deal with that scenario? I hope that the Minister will elaborate on that, because it causes me more concern than any of the other proposals. I understand the need to free up resources, and perhaps he wants to have more ambulances so that we can speed up response times, but I ask him to look at the four-hour target first.

Edward Timpson: I am grateful to my hon. Friend, who has got to the nub of the issue. One of the community first responders in Nantwich has told me directly, "I wish I didn't even have to be here." He said that he had to fill in the gaps, as my hon. Friend says, to ensure that there was a proper service that met the needs of the local people of Nantwich. Although he enjoys his job and gets great satisfaction out of it, he would prefer not to have to do it. If there were a 24-hour paramedic service on the doorstep of everyone who lives locally, he would certainly not have to.
	A process is taking place that the North West Ambulance Service calls a "standardising" of the service. It is essentially downgrading the role that community first responders play in the local community. It is taking away the life-saving drugs that they administer at the scene of an accident or in a case of trauma, and reducing their responses to certain calls such as those involving children. Perhaps most concerning of all, it is taking away their ability to use a blue light as part of their response. The original intention behind community first responders was, to quote a report by the Healthcare Commission on the Staffordshire ambulance service,
	"to provide a prompt emergency services for communities that ambulances could not reach so quickly, and to improve the outcomes for patients where the speed of the first intervention can be critical, especially those with chest pain or having a cardiac arrest."
	The removal of the blue light has disabled community first responders from ensuring that they can get to the scenes of category A and other calls as soon as possible. As a result, the number of calls to community first responders in the Nantwich area has been reduced from about 80 a month to just one or two a week.
	Sadly, the removal of those responsibilities of community first responders last May came at a time when a young father in my constituency needed their help. In a tragic incident, the ambulance was unable to reach him within the specified 8-minute period. The community first responder was not called, because of the downgrading of the service, and the young father died. The justification for the standardising of the North West Ambulance Service was the Healthcare Commission report that I have just cited, but of course the role of community first responders is different for each trust. In Nantwich, the responder is someone who not only has many years' experience in the role but is qualified at the highest standard to drive with a blue light. It seems bizarre in many respects to take away the opportunity for him to respond as quickly as possible, given that he has both the training and professionalism to do so. He has done so for four years with no incident. Restricting the capabilities of the community first responders potentially puts lives at risk.
	The Secretary of State said earlier that he wanted change for the benefit of patients. We certainly want such change, but we have not seen evidence that the changes to the responsibilities of the community first responders are an example of that. The depth of feeling about their role is palpable in my constituency, as I am sure it is in constituencies across the country. The situation has led not only to a petition of more than 10,000 local names being signed and delivered to Downing street but to the first march through the streets of Nantwich for a considerable time. Having spoken to some more expert local historians than I, I understand that it is the first since the civil war. That is how strong the local feeling is. The community first responders are held in very high regard and provide a valuable service. The sooner a highly qualified community first responder can be on the scene, the greater the chance of a successful outcome.
	We have been told that the North West Ambulance Service wants to expand the community first responder service, and indeed it has started to make moves in that direction. However, new CFRs are becoming qualified on the basis of just 18 hours of training, without responding to the category A, B and C calls that, as the hon. Member for Wyre Forest (Dr. Taylor) pointed out, need to be recognised as part of their service. That seems an unfortunate way in which to treat people who volunteer their services and have the capacity to ensure that the response times are met. They also offer two other benefits.
	First, community first responders are great value for money—they do not ask for anything for their actions; indeed, they plough in their own money to perform the task. Local financing—often given by town councils and other charities—covers their role. They therefore provide a direct benefit to the NHS and the local community. Secondly, they are not only locally accountable but they have immense local knowledge. An ambulance that comes from many miles away may have directions about how to reach the patient, but the driver may not know the patient, and may not know the road intimately or be able to get there as fast as a community first responder. Local knowledge is therefore vital in providing the service.
	It is time for ambulance trusts throughout the country, especially in my area, as well as the Government, to listen to the voice of the public about a service that is vital but currently undervalued. The community first responders have shown that they are willing not only to serve but to give to the best of their ability. It is only right that they are allowed to do that.

Michael Penning: It is a pleasure to respond to the debate on behalf of Her Majesty's Opposition on such an important subject, which affects all our constituents and the whole country.
	I pay tribute to all staff in the NHS, whether in the emergency or primary care sectors. They do a wonderful job and we should praise them at every opportunity. I also take the opportunity, following my recent visit with other parliamentarians to Afghanistan, to praise NHS staff serving in the Territorial Army, especially in the emergency centres and triage centres in places such as Camp Bastion, which could not survive without the NHS contribution to our armed services. Their work there is simply fantastic.
	We are in a sad predicament. At one stage, when I looked at the Government Benches, I thought I was in an Adjournment debate. Only one Labour Back Bencher made a speech on the NHS. Remember 1997 and "24 hours to save the NHS"? Yet the Government Benches could not be filled for such an important debate. Only one Labour Back Bencher, who is desperate to save her seat, contributed. If she returns, I shall consider her speech shortly.
	Let me consider the Secretary of State's opening remarks. I want especially to deal with urgent care. It worried me that the right hon. Gentleman appeared to refer to another review, which may happen sometime in future, into urgent care, especially a second emergency number. In looking at my notes, it was interesting to remember that the Government promised us a framework for urgent care three years ago, in 2006. Six months later, Lord Warner promised a strategy by the end of the year. In the first half of 2007, the right hon. Member for Doncaster, Central (Ms Winterton) promised that we would have an answer about the secondary number. Again in 2007, Lord Darzi mentioned it in his reports. Now, in early 2009, the Secretary of State mentions it again. We do not need it to be mentioned; we need action.
	This morning, Ofcom stated in its parliamentary briefing that it would conduct an immediate review—I hope that the Secretary of State is aware of today's announcement—and that it will look into the numbers that are available as well as 999. I will deal later with some of the comments about whether we need a second number or whether everything can be done through using 999.
	Ofcom has specifically said that it would be inappropriate to use 888. Most people understand that, especially those who live in London. Anyone in the area covered by the 7 code who had to dial 8 could end up dialling 888 inappropriately. However, Ofcom has suggested that it would be possible to use not only the 116 116 numbers, with the permission of our European friends, but triple numbers from 102 to 119, including 117. Myriad numbers are available should the Government wish to proceed. Ofcom is on board. We have been calling for the change for two and a half years. It is imperative that the public have a simple way of accessing urgent care, not myriad different services all the way through.
	We have heard many contributions today, mostly from the Benches behind me, and it is important that we consider some of them. The Liberal Democrat spokesman, the hon. Member for Romsey (Sandra Gidley), talked about 116 numbers, but she was slightly confused when she said that she did not want the public to go through an operator system. That is not what is proposed. Most of the ambulance trusts operate a system similar to what is proposed already. My concern is duplication. We do not have unlimited cash in the NHS. We cannot have the public confused with different numbers; nor can we have the cost of different services by different agencies.
	There was also some confusion when the hon. Lady responded to the interventions that my hon. Friend the Member for West Chelmsford (Mr. Burns) made on her. The ambulance service is a complex system and we need to try to understand how it operates. I ask the hon. Lady to go to one of the ambulance trusts and to sit there while staff are doing a triage call, because it is fascinating. The minute a call comes in, staff are dispatched, based on the location of the call. They would much rather turn back an ambulance or downgrade a call than worry that they were not getting people there.
	There is a concern about the eight-minute call, which means that staff need to get someone there within eight minutes 75 per cent. of the time. We understand that. What cannot happen, but what is happening—this has followed the amalgamation of the ambulance trusts, although I do not think that it was intentional—is that, because the number of responses getting there in time is grouped, if an ambulance trust has an urban and a rural part, which most do, it can have an attendance rate of almost 100 per cent. in time in the urban part, but almost zero in the rural part. I am sure that that is the point that the hon. Lady was trying to make.

Michael Penning: No, I have to stick to my time; that is the problem with this sort of debate. The point is that the issue of the 116 number could be addressed almost immediately.
	I am really disappointed that the right hon. Member for Enfield, North (Joan Ryan) is not in her place. She made a contribution of nearly 15 minutes, in which her position on the future of Chase Farm hospital flip-flopped. In the consultation on Chase Farm she opted for option 1, which is to downgrade the Chase Farm A and E facilities. That was her position then. Her position today is that she is fighting to keep all the facilities at Chase Farm. The right hon. Lady cannot have her cake and eat it. Either she is for her Government, who are willing to close the A and E department at Chase Farm, or she is not. It will be this Government who will close the A and E departments at Chase Farm hospital, at Welwyn Hatfield hospital and, yes, at Hemel Hempstead hospital. That is something that I go on and on about, and I am very proud to do so. The reason why I go on about it so hard—it is also why my hon. Friend the Member for Enfield, Southgate (Mr. Burrowes) is in his place, unlike the right hon. Member for Enfield, North—is that the community does not want to lose the life-saving facilities that they have now.
	The Secretary of State was trying desperately to say that we should take no notice of the experts who say that an urgent care centre—or whatever title we want to use—is not a replacement for an A and E department. The right hon. Lady went on about the myths propagated in her constituency; and interestingly enough, she came up with a myth herself. She should have looked at the report that the College of Emergency Medicine published just before Christmas. The College of Emergency Medicine issued a list of myths, and the right hon. Lady managed to hit the first one. "Myth 1," the College of Emergency Medicine says, is that
	"60 per cent. of patients attending an A&E department could be seen, to the same clinical standards, at less cost, in other settings"— [ Interruption. ]
	I understand from my hon. Friend the Member for South Cambridgeshire (Mr. Lansley) that the Secretary of State said the same thing. In fact, the College of Emergency Medicine—I am sure that the Secretary of State would agree that it is an expert—says:
	"Between 5 and 10 per cent. of patients attending an Emergency Department...should be treated in primary care".
	We accept that. It continues:
	"Another 20 per cent. of patients could be treated in primary care"
	settings, but that is it. So the absolute maximum percentage of patients attending an A and E who could—not should—be treated is 30 per cent. The myth propagated by the Secretary of State and by the right hon. Lady is that it was 60 per cent. That, frankly, is wrong.
	My hon. Friend the Member for West Chelmsford provided a wealth of experience—not only from his time as a shadow Minister, but as a member of the Health Select Committee before my time on it—and showed us just what could be done if we engage with the hospital in the local community. The information that he put forward was absolutely vital. I completely agree with him that many of the problems of emergency departments are to do with alcohol and alcohol abuse, and I agree with him about the assaults and abuse that NHS hospital staff have to take. The Government could do something about that tomorrow—and the Secretary of State could do something about it tomorrow. Why are only one in 1,000 assaults on our brave and professional emergency staff prosecuted? Perhaps the Secretary of State or his ministerial colleague would like to intervene to explain why our staff are assaulted on a daily basis, yet prosecutions do not take place. The right hon. Gentleman said at the start of his speech that he was dedicated to the staff and he praised them, so why are we not protecting them? My hon. Friend raised a very important issue.

Michael Penning: I stand corrected. This is fantastic: the Great Western trust is being looked after by the West Midlands trust, because the Great Western could not look after the situation itself; as its results were so poor, Anthony Marsh, the chief executive of the West Midlands trust, has gone across to help it. Let us hope that the situation improves.
	The hon. Member for Wyre Forest also spoke about a very sad case of a young boy who died in his constituency. I am sure that all our thoughts and prayers are with the family. It is so difficult when that sort of things happens in our constituencies, as it does every now and again. People needed the help of the NHS; sadly, they were let down. We look forward to seeing the results of the inquiry.
	My hon. Friend the Member for Mid-Bedfordshire (Mrs. Dorries) never ceases to amaze me with her depth of knowledge. She worked in this sector and took a huge interest in health issues while she was there. Many of us may have worked in different areas of different industries over the years, but we have not absorbed to the same extent as her an understanding of where the problems lie. My thoughts were with her as she talked so powerfully about the loss in her family.
	I bring my own experience to the subject of what used to be called road traffic accidents—we have changed the language over the years, but I will continue to call them RTAs. When I first joined the fire service, I came in with a paramedic qualification from the armed forces. I was asked to take a first aid course. That is where we were. I sat so often at road traffic accidents and saw how the medics—there were no paramedics in those days—did their very best to keep going the vital signs of people who we were trying to extricate from vehicles. Very often, people died. I had the most appalling experience with a young lady who had a stoved-in chest and was drowning internally; no one had the ability to drain her or keep her airways open. That, thank goodness, has changed.
	Although I understand my hon. Friend's concerns about single responders, I have been present at RTAs that it has been physically impossible for an ambulance to reach—let alone an air ambulance, if one was available. Bikes do get through, however. She is right that they are not a replacement for a two-crewed ambulance, and it is vital that ambulances are dispatched at exactly the same time. I also understand her point about all the different techniques such crews need to have, and that it is better to have six hands than four or even two. Two is better than none, however; I have been at RTAs where there have been none, and it is better to have someone there. I agree that we must make sure that we do not only have single responders, but I do not think that is the situation; I have not met an ambulance trust chief executive who has told me that they have only single responders to RTAs, and I have asked every time. If that were ever brought in, it would be fundamentally wrong, and I am sure the Secretary of State would object to that, too.
	However, there is a crisis in the ambulance service involving the difference between paramedics and technicians and what has been described as the wonderful new skilled roadside role of the emergency care assistant. I had in the past understood that in no situation would an ambulance go out without a paramedic or technician on board, but it is now my understanding that at present ambulances are responding to emergencies with under-qualified staff on board and they are invariably called emergency care assistants. That is very worrying. Over the years, we have built up the skills of paramedics. They have increased, not least because of the extra skills they pick up on operations with the military and then take back into the domestic sector. We cannot go the other way, and allow decreased skills. At present, we have paramedics on the one hand and emergency care assistants on the other hand, and something is falling through the middle: the skill base that we would all want.
	Let me say a few words about queues outside hospitals. Ambulances queue up and hospitals will not take patients in because they are worried about the four-hour limit. This is no criticism of the West Midlands trust, but let me explain a situation I learned of while visiting Birmingham recently. There were 17 of the trust's ambulances queued up outside a hospital, and the only way they could be freed up was by putting one of the senior ambulance officers into the porch area of the accident and emergency department so that the ambulance crews handed over patients to her but not to the hospital. If that is what happens in a modern hospital service in the 21st century, something is seriously going wrong. I understand that happens around the country. It is one of the ways that ambulance trusts manage to free up their vehicles and get them back out on the road again; they have to avoid getting their patients into the hospital accident and emergency department because there is concern about the four-hour target.
	My new colleague, my hon. Friend the Member for Crewe and Nantwich (Mr. Timpson), raised an important point about how communities feel about responders. Although they are unpaid, I have to emphasise to him that they all need to learn their skills. They need to come out of their basic training; 18 weeks is a short period but it is long enough to get their basic skills together. The key is that skill base as we take them forward. If we just left them with 18 weeks of training, and they went back in the community and never had any further training, that would not be useful. In terms of my hon. Friend's comments, what particularly worried me is that the critical care they give is key, so excluding them from category A—in other words, saving lives at critical points—is the opposite of what we should be doing. In many respects, their job is to save lives, not just to patch up a fracture or tend to a sprained ankle. It is crucial that we use them with such necessary skills, rather than pushing them off to less important roles. I will take that issue up in my shadow role.
	When making notes for winding up this debate, I particularly wanted to talk about the ambulance issue because I knew that my hon. Friend the Member for South Cambridgeshire was going to talk in his opening remarks about the accident and emergency issue. I did not want to talk only about emergency care assistants or the emergency response times. I do not think that the Government intended to happen what is happening when they moved to regional ambulance trusts, but it is happening; if the ambulance trusts were smaller, it would be more difficult for the figures to become skewed between rural and urban.
	I covered the way in which the performance targets work—that is a major issue and I hope that the Minister will examine it. The crucial thing when examining the performance of a trust is that we examine the outcomes. He is disagreeing with most things that I am saying, but if he thinks that the accident and emergency facility at Chase Farm should be closed, as is proposed, and that the accident and emergency closures that affect the Welwyn Hatfield area should proceed, or if he wants to continue with the mad closure programmes for the Hemel Hempstead general hospital, he should call an election—he should go to his boss and say, "Let the people decide." The Secretary of State says that he wants local democracy, so let us have an election and let the people decide.

Ben Bradshaw: I assure the hon. Member for Hemel Hempstead (Mike Penning) that I was shaking my head not because I disagreed with all of what he said—I think that there is a great deal of consensus on these issues—but because he took 20 minutes to say it. The debate has generally been good and positive, and we have heard many interesting and constructive contributions from across the House. We could have had an even broader debate, given that the title of the debate covers a range of issues; it covers not only the ones that we have discussed, but walk-in centres, general practitioners, out-of-hours services and NHS Direct. Urgent and emergency care is a broad canvas indeed.
	I shall concentrate on the specific points that have been made, but if I do not have time to respond to all of them, I shall endeavour to write to hon. Members.

Ben Bradshaw: Absolutely. The hon. Gentleman has pointed to the inherent contradiction in the Conservatives' policy: they say that they recognise the need for reorganisation, including the creation of trauma centres—the need for which he has described—yet they oppose every single reorganisation on the ground when one is actually proposed.
	I need to correct the figures, or the impression, given by the hon. Member for South Cambridgeshire (Mr. Lansley) about the increase in accident and emergency attendances. A small increase in the number of such attendances took place between 1997 and 2003, but between 2002-03 and 2007 the figures for the average annual increase in accident and emergency attendances were as follows: the figure for major accident and emergency departments was 2.2 per cent.; that for single specialty accident and emergency was 4.9 per cent.; that for other types of accident and emergency department, including minor injury units, was 4.6 per cent., and that for walk-in centres was 15.7 per cent. Hon. Members can see that the biggest single proportion of the increase in accident and emergency attendances arose because of walk-in centres, which did not even exist under the previous Government, and that the smallest increase was for major accident and emergency departments.  [Interruption.] The figure is not going up; the hon. Gentleman is wrong about that, too. The 2007-08 figures for major accident and emergency departments—the latest ones—show that there was a reduction of 1.5 per cent. compared with the previous year.
	On the general issue of accident and emergency provision, a number of hon. Members have, fairly, recognised that the latest independent health watchdog report by the Healthcare Commission not only reports an improving picture—88 per cent. of the public rate their experience of accident and emergency as excellent, very good or good, which is an increase from 85 per cent. in 2003-04—but makes a number of criticisms, including some associated with pain relief and discharge, which the Government take very seriously and expect the NHS to address.
	The hon. Member for South Cambridgeshire gave the reply that I was going to give in response to the hon. Member for West Chelmsford (Mr. Burns) on the gap between the findings of the Healthcare Commission's survey and the official figures. That occurs because some people may, for clinical reasons, need to be to moved into an assessment unit or a side ward if the consultant who has seen them is not in a position at that stage to make a decision on their care. Such people may still feel as if they are in accident and emergency, whereas in fact they are not. That four-hour target, which the Conservative party would scrap, has been incredibly important in driving up performance. I do not know any serious manager in the health service who thinks that it would be a good idea to abandon it. That would be a recipe for returning to the terrible days of patients having to wait hours, and even days, on trolleys, and the closure of accident and emergency departments.
	It is important to put on the record what the College of Emergency Medicine report said about emergency medicine. It has been widely, but selectively, quoted by the Opposition, including in an early-day motion, but they omitted to mention that the report states on page 8:
	"There is no single solution to the reorganisation of emergency care. In urban areas where"
	emergency departments
	"are close together (less than ten km apart) there may be advantages to amalgamating some services."
	It goes on to argue that that could result in a "more coherent" service for local residents.
	The college's report states that throughout the country, many patients who currently attend A and E but do not need the full services of an acute hospital could be dealt with in an urgent care centre on a hospital site or in a community setting. The recent independent Healthcare Commission report on urgent and emergency care found that, in a typical urgent care centre, care starts within an hour for 93 per cent. of patients.
	There is evidence of highly effective urgent care centres that are properly integrated, and have good collaborative working relationships with A and E colleagues. The key issue is that services should be integrated and staffed by people with the right skills and competencies to deal with the population using the service. Whether an urgent care centre is appropriate in a particular area, and how services are best structured, will depend on local circumstances. The Opposition motion suggests that to achieve that may mean concentrating expertise in a smaller number of centres of excellence that bring together specialists in different subjects to work together as a single team.
	Many people who walk through the doors of accident and emergency departments do not need such a high level of care, and for them the most effective treatment will come from a nurse or GP. We can trade figures, and other reports have been quoted, but I am advised that the most conservative estimate is that 50 per cent. of those who present in accident and emergency departments in fact require primary care. That is a huge proportion.
	Of course, when any reorganisation takes place it can be, and often is, controversial. But as my right hon. Friend the Secretary of State made clear in his opening remarks, the changes must be locally led, clinically driven and, in contrast with what the hon. Member for Mid-Bedfordshire (Mrs. Dorries) suggested, they require full public consultation. If democratically elected local councillors disagree with recommendations made by their local primary care trusts, they can object through the overview and scrutiny committee and refer those proposals to the independent reconfiguration panel. Some hon. Members have said that the panel is just a front, but in the past six months it has comprehensively rejected two major reorganisations, one in Oxfordshire and one in Sussex. It bases its decisions on the clinical case, and it was absolutely right for my right hon. Friend to take the politics out of the matter and set up a process that is transparent, independent, and based on clinical need and what is best for the patient.
	My right hon. Friend the Member for Enfield, North (Joan Ryan) has championed Chase Farm hospital with great effect during her years in the House. I am sorry that she was not in the Chamber for the contribution by the hon. Member for Hemel Hempstead, but she may like to read the  Hansard record, because he grossly misrepresented the position on Chase Farm and what she has done to ensure that the proposals affecting Enfield are much better than they were at the outset.
	My right hon. Friend took the trouble to highlight the fact that many of the improvements in the NHS in her constituency, including GP-led health centres and the planned new polyclinics, represent developments that the Conservative party oppose—her local Conservative party is completely silent on that subject. We have had many such debates, and the national director for emergency access referred to the proposals from the local primary care trust—not the Government—on the reduction from three to two accident and emergency departments. He said:
	"Put starkly, it is evident that safe, high quality modern care cannot be provided for all specialties in all three acute hospitals in the area...Care of the standard that members of the public have a right to expect will require the centralisation of some specialties on two of the three hospital sites. Immediate care around the clock by experienced clinicians cannot be guaranteed whilst efforts are made to maintain all three sites".
	My right hon. Friend will also be aware that there is an outstanding judicial review application by the local authorities concerned, but the challenge from the local authorities to the Independent Reconfiguration Panel was not successful.
	The hon. Member for Romsey (Sandra Gidley) raised the issue of ambulances in some depth, but she did not mention that we are achieving the best ever response times. The ambulance service is the most popular in the NHS, as it scores the highest level of patient satisfaction of any service—some 97 per cent., according to the independent Healthcare Commission. Investment in ambulance services has increased by 135 per cent. since 1997.
	The hon. Lady raised the specific issue of ambulance services in rural areas, and how the new larger ambulance services are expected to perform. The Department issued directions to each ambulance trust following the reorganisation of services in 2006 to set out the requirement that each trust must be able to demonstrate that it has regard to the reasonable needs of everyone in their area, and has arrangements in place to meet the national response times. The way in which each trust does that will depend on the local geography and fleet mix, and is a matter for local decision. However, since the reorganisation, ambulance services have improved their performance and displayed the highest response ever on category A calls, with 77.1 per cent. in the latest figures.
	The hon. Lady—and the hon. Members for Mid-Bedfordshire and for Hemel Hempstead—also raised the issue of delayed handover of patients at accident and emergency departments. Let me make it clear again—as my right hon. Friend the Secretary of State has done on many occasions—that it is totally unacceptable for A and E departments not to accept patients, or for ambulances to have to wait outside for whatever reason. Hon. Members will be aware that the accident and emergency clock starts when the handover occurs or 15 minutes after the ambulance arrives, whichever is earlier. So if hon. Members wish to make specific allegations about such problems occurring at a hospital, they should let us know and we will come down on that hospital like a ton of bricks.
	The hon. Member for Wyre Forest (Dr. Taylor), and others, raised the issue of the three-digit number. I am sorry to have to say that they will have to be patient for a little longer. As the hon. Gentleman acknowledged, it is a complex issue as several different models could be implemented. As he knows, we were clear about our commitment in the next stage review, and it is important to consult on the different models with all the different organisations involved, in the public interest.
	The hon. Member for South Cambridgeshire rightly raised the concern about the pressure on accident and emergency departments caused by alcohol and drugs. He will, I am sure, be aware of the cross-Government strategy on alcohol and drugs, which aims to address the three problem drinker groups, and therefore take the pressure off accident and emergency departments.
	The hon. Member for Mid-Bedfordshire also raised concerns about solo response teams, and I will write to her in more detail. What I can say is that if, according to the best knowledge and decision making of the trust, a traditional double-crewed ambulance is required, one should always be sent—but it is important to provide a fast response as quickly as possible, with back-up if necessary.
	We do not have to cast our minds back too far—just to the mid-1990s—to remember the horror stories of people waiting for days to see a doctor, waiting in corridors on trolleys in accident and emergency departments. They were waiting with neither privacy nor dignity at a time when they were at their most vulnerable. Over the past decade, this Government have transformed people's experience of urgent and emergency care. Ambulance services and accident and emergency departments are scoring record performances with a huge expansion in alternatives to urgent care for people for whom accident and emergency treatment is not appropriate. That is an enormous tribute to NHS staff, and I commend our amendment to the House.
	 Question put (Standing Order No. 31(2)), That the original words stand part of the Question.
	 The House proceeded to a Division.

David Winnick: On a point of order, Mr. Deputy Speaker. Will you confirm that it is not intended to move the freedom of information order that is on Thursday's Order Paper? If so—and I believe that it is—many of us will welcome the fact that we will not be exempted from freedom of information legislation. That was passed by the House, it applies to others and obviously it should apply to us. The move is very welcome, and I hope that you will be able to confirm that what I have just stated is the position.

Philip Hammond: I hope that the hon. Gentleman will bear with me, because, as he might have anticipated, much of the remainder of my speech will set out the things we would have done, some of which the Government have now adopted in their package of proposals.
	Members will recall that the Prime Minister thinks that he saved the world. The Employment Minister apparently sees light at the end of the tunnel, Baroness Vadera sees some green shoots and the Housing Minister apparently sees an upturn in the housing market. However, I have to say to the Financial Secretary to the Treasury that everyone else—every commentator, every market, the European Union, the OECD—sees unrelenting gloom, and a longer and deeper recession in the United Kingdom than in any other major economy.

Emily Thornberry: Over the past few years half of the homes in Islington have had their roofs fixed as a result of the decent homes programme. Thank goodness for a Labour Government for that.

Philip Hammond: The hon. Lady obviously thinks that that is a very clever intervention.  [ Interruption. ] Well, it has been done before, but usually with school roofs. She makes my point precisely. During the good years, the Government borrowed yet more money that they do not have and spent it, and now we have come to the recession the cupboard is bare. The Government have no room for a responsible fiscal stimulus, while many of our neighbours in Europe find that they do have such room.
	There is an emerging consensus that a fiscal stimulus is not appropriate in these circumstances, and I shall set out what those circumstances are. There is a huge current budget deficit. The Economic Secretary thinks that that is funny; his Government is going to run up a budget deficit of £118 billion. Household debt stands at £1.4 trillion. There is a pattern of persistent and huge external deficits. We have a rapidly weakening—some would say collapsing—currency. There has been a record of absolute failure during the past seven years to deliver the fiscal projections made in Budget after Budget, and we have an unbalanced and highly exposed economy.

George Mudie: If the argument is that we started in a bad position with no fiscal room, what is the hon. Gentleman suggesting in fiscal terms? Is he saying that we cannot do anything because of our starting point? If he is saying that, I would point out that the motion on the Order Paper would cost £4.1 billion. Where will that come from?

Philip Hammond: The Government were projecting increases in spending totals that would see public spending decreasing as a share of GDP, taking on the prudent approach that we have been advocating and which they have singularly failed to adopt in the last few years.
	The Government will quote in their defence sources that are generally supportive of fiscal measures—that is to say, people who tend to be on the fiscal side of the academic debate or who recommend a balance of fiscal and monetary initiatives.  [ Interruption. ] We can quote some Germans if the Economic Secretary really wants us to; I have my Germans all lined up in a stack of papers on the Bench. What the Government will not tell us is that most of those people, under questioning, readily concede that a fiscal stimulus is not only inadvisable, but positively dangerous in the UK's current circumstances. Some have issued specific warnings against the UK adopting a fiscal loosening. For example, in the European Commission's economic recovery plan that we debated yesterday, we find on page 7:
	"It is clear that not all Member States are in the same position. Those that took advantage of the good times to achieve more sustainable public finance positions and improve their competitiveness have more room for manoeuvre now."
	It continues, and I invite my hon. Friends to try to spot the reference here:
	"For those Member States, in particular outside the Euro area, which are facing significant external and internal imbalances, budgetary policy should essentially aim at correcting such imbalances."
	In other words, there is no room for fiscal loosening. Jean-Claude Trichet, the president of the European Central Bank, warns:
	"If you augment too much your own borrowing, you might be punished by markets. If you are at the limits of what you can do, you can lose more with absence of confidence and loss of confidence than you would gain from the simple channelling of additional spending."
	That is the very point that my hon. Friend the Member for Reading, East (Mr. Wilson) made about the nation's credit rating.

Philip Hammond: As my hon. Friend will know, we have been calling for a very long time for the Government to publish their response on Equitable Life. We were surprised by the reference to the possibility of means-testing, but we will await the outcome of the deliberations that have been set in train to see exactly what is proposed for Equitable Life members. The Government need to ensure that that outcome is published sooner rather than later.  [Interruption.] I hear the sedentary objection of the hon. Member for Leeds, East (Mr. Mudie) that I have not yet mentioned savers, but the title of the debate on the Order Paper is the "Effect of economic policy on savers", and I wish to spend another minute at most setting out the economic policy background. I shall then explain its impact on savers.
	The point of my build-up is to make it clear that monetary intervention should be the principal tool for addressing a recession that is born of a credit system failure. It is wrong to pile up more debt to try to solve a problem caused by excessive borrowing. The Government should learn the simple and obvious lesson that one cannot borrow one's way out of debt.
	We now have in place measures to support banks' ability to lend and borrow, through guarantees and the ring-fencing of toxic assets; direct lending to larger companies; reductions in interest rates in response to the threat of declining inflation; and, tucked away in the small print of Monday's announcement, preparations for quantitative easing—the printing of money—as a contingency. Those are the weapons that are now deployed in the battle to rescue Britain's economy.
	Let me say clearly that it is a good thing for the economy that interest rates are falling. The sharp decline in the retail prices index posted yesterday and the 1.9 per cent. gap between RPI and RPIX, which essentially reflects changes in mortgage interest costs, underscore the massive effect of a monetary stimulus. For almost every family in Britain that has a variable rate or tracker mortgage, the impact of lower mortgage costs will far exceed the impact of the Government's so-called fiscal stimulus. Since October, interest rate cuts have saved British home owners billions, dwarfing the impact of the VAT cut.
	However, that welcome relief comes at a price for all those who depend on savings and modest investments for their income. That means millions of British householders, almost by definition including many older people, who have done exactly the right thing for years, probably decades. They have saved diligently as they have worked hard, set their faces against the "buy now, pay later" culture and presciently been wary of the Prime Minister's boast to have ended boom and bust, and they have cautiously built some savings to fall back on in hard times. In short, they are the very people who have done what successive Governments have asked them to do—people who have behaved responsibly during the Prime Minister's age of irresponsibility. Now they are seeing their savings income slashed and their plans destroyed. To add to their anguish, many of them will have had small holdings in bank shares, which are a favourite of small investors and particularly of pensioners. Those holdings will have been almost completely annihilated in some cases.
	We estimate that savers have lost something of the order of £22 billion of annual interest income as a result of the rate cuts over the past few months. Thirty-eight per cent. of no-notice accounts now pay less than 1 per cent. interest. Some banks, for example, the Julian Hodge bank—one or two older Labour Members may remember that name—already offers 0 per cent. to savers with less than £1,000. Members of all parties will have anecdotal examples of constituents who are often retired and perhaps live on small company pensions plus state pensions, supplemented by a modest income from a small accumulation of lifetime savings. In many cases, the annual or semi-annual credit of interest to their accounts represents the only available free cash to buy small luxuries or replace big ticket items. Those people now feel betrayed. They are confused about why they should be punished, and bewildered by the fact that those who saved thriftily have to pay the price for a crisis created by those who borrowed and lent profligately.
	The reasonable expectations of many millions of people, who have worked all their lives on modest incomes but have none the less scrimped and saved to support themselves in their retirement, are being dashed. They are the innocent victims of Labour's recession. They deserve better.
	We believe that Government have a responsibility to help people through the recession and, therefore, earlier this month, my right hon. Friend the leader of the Conservative party set out our proposals to deliver help to those who have suffered most from the collapse in interest rates, which has benefited those of us who are borrowers. Under our plans, the basic and lower rates of tax on savings income would be abolished. That means that anybody who earns less than £32,000 a year and has savings income will pay no tax on that savings income. That means a potential saving of up to £7,200 a year. In addition, we will increase the tapered older person's tax allowance by £2,000 a year, thus providing more support for those above retirement age, who are basic rate taxpayers and who find that the decline in their savings income means that they need to work to make ends meet in retirement. They could be up to £400 a year each better off after tax.
	There is a further bonus for some of the lowest income savers in the country. Her Majesty's Revenue and Customs estimates that 3 million people in this country, who are on low incomes and are small savers, pay too much tax on their savings interest because they fail to claim the basic rate tax deducted at source, even though they are not liable to pay it. Under the Conservative plan to abolish savings income tax for all basic rate taxpayers, the banks and building societies would no longer deduct tax at source, ensuring that the 3 million low income savers would not pay unnecessary tax. At the same time, the tax system would be simplified.

Philip Hammond: The hon. Gentleman is right to the extent that the package covers people who have planned throughout their lives on the basis that they were accumulating savings to provide themselves with an income in retirement. Their circumstances have radically changed through what has happened to interest rates in the past few months. He makes an important point about ISAs. Of course, they are available, but 60-odd per cent. of small savers and a disproportionately high percentage of pensioners prefer to save in ordinary bank or building society accounts. Frankly, it is not for the Government how to tell them how they should save. We need to adapt the system to accommodate the problems that they are now facing rather than airily telling them that there is a solution if only they would do things in the way in which the Government would like.

Kelvin Hopkins: Following the question from my hon. Friend the Member for North-West Leicestershire (David Taylor), he will know that something like £20 billion is already spent on tax relief for savers. The overwhelming majority of that goes to the rich and the better-off. Could not the hon. Gentleman pay for his scheme simply by taking away that £20 billion? If he does not do that, he will make the fiscal situation worse.

Philip Hammond: If the hon. Gentleman has not already looked at our policy, which was announced several weeks ago, he should bear with me for a moment to understand exactly how we are going to pay for our proposal, which I shall spell out.
	Let me first give the House some examples of how our proposal will affect people. A 60-year-old couple who are retired and have a total pensions income of £12,000 a year each would be about £400 a year better off. A 40-year-old single mother who works part time and earns £10,000 a year, but who has some savings that produce £800 a year in income, would be £160 a year better off. Those over the retirement age who benefit from the older person's allowance do even better. A 65-year-old couple who are retired with a total pensions income of £14,000 a year each currently pay £902 in income tax each, which amounts to £1,800 in total. The tax bill on their pensions would fall to just £502 each, making them about £800 better off in total. If they also had £1,000 a year each in interest from savings, they would pay nothing at all on that savings interest and would save another £400 a year, which means that they would be £1,200 a year better off in total. I could give other examples.

Philip Hammond: The hon. Gentleman is deliberately missing the point. There is always a case for helping the poorest pensioners, of course, but this is a specific initiative designed to deal with a group of people whose income has been catastrophically reduced in a very short period of time, and many of them, because they are retired, are no longer in a position to do anything about changing their planning for retirement. I am sure the hon. Gentleman has constituents who have contacted him to tell him that they are in such a situation. This is a targeted measure to deal with a particular group of victims of this recession who have been severely affected, and in our view the responsibility of Government in a recession is to try to help those who are worst affected by it.

Philip Hammond: The Financial Secretary is right in what he says about ISAs, but will he confirm that one in three savers are not saving through an ISA and that 40 per cent. of pensioner savers do not have ISAs? Older people perhaps tend to stick with what they know and, as I have said, we should change the system to accommodate them, rather than expecting them to adapt to the system.

Philip Hammond: I must pick the Minister up on his use of slack phrasing. The proposal is not to cut Government spending but to restrict the growth of public spending to a slightly lower level than that proposed by the Government.

Kelvin Hopkins: I agree very much with what my right hon. Friend is saying. The Opposition are talking about making Budget cuts worth £5 billion, and it is clear that local government—and especially children's services—would be in the firing line. Budgets for children's services are under pressure already, but does he agree that the danger is that they could suffer even more, with the result that there would be more cases such as those of baby P and Victoria Climbié?

Stephen Timms: My hon. Friend is right. I think that local government would have to bear some £240 million of the cuts, and that children's services would have to accept their share of that. The Opposition's draconian proposal is being rushed forward on the pretence that everything could be done in a few weeks, when it clearly could not. It is especially ill advised to bring the proposal to the House at this point in the cycle, just as we enter the major downturn that all of us can see, and which the International Monetary Fund has talked about.

Stephen Timms: The announcements in October succeeded in saving the banking system. That has been recognised very widely, and this week we have set out a further set of measures aimed at restarting lending. In particular, the measures reflect the fact that so many non-UK banks have withdrawn lending. The Icelandic banks are the most obvious examples, but there are others as well. The measures are designed to fill some of the need that has not been filled until now.
	I want to say a little more about the proposal that the hon. Member for Runnymede and Weybridge has put to the House. It is a classic "robbing Peter to pay Paul" policy, of the kind that only the do-nothing party opposite could have devised. I have mentioned the obvious problem with cutting Government spending as we go into a recession. If the hon. Gentleman does not know what the problem is, I am certain that the new shadow Business Secretary will be happy to explain it to him.
	The hon. Member for Runnymede and Weybridge has said roughly what he would do to fund his proposition. What is the benefit of the savage and swingeing cuts that are being proposed? He has not explained the planning behind them, or how they will be drawn up as we go into a recession.

Mr. Deputy Speaker: Order. Before I call the Liberal Democrat spokesman, may I inform the House that an eight-minute limit on Back-Bench speeches will apply once the Liberal Democrat spokesman has finished his remarks.

Vincent Cable: I shall try not to test the patience of the House by giving another political rant on the state of the economy, the banking system and the rest of it. I will try to pay the motion the compliment of addressing the issue that it raises: the problem of savings. That is an entirely proper issue and it is timely. For the most part, I agree with the motion, but not with all of it.
	I detect that the shadow Chief Secretary's speech is becoming a bit of a stump speech. It has at its heart two powerfully argued propositions, one of which is that this is a disastrous Government pursuing disastrous policies. The second is that this is an ungrateful Government pursuing Conservative policies and not expressing proper appreciation for doing so. From the Liberal Democrat point of view, those are entirely consistent arguments with which we have no difficulty in agreeing, but the hon. Member for Runnymede and Weybridge (Mr. Hammond) may have to decide which of the two he wants to pursue.
	The hon. Gentleman is right that there is a savings problem. Savers are among the biggest casualties of the recession and it is right that we focus on why that is so and whether anything can be done to remedy their problems. He focuses on one group of savers who have a problem—people with variable interest deposits in banks. I am not sure what share of total British savings they account for, but almost all the hon. Gentleman's policy prescriptions are based on that narrow, specific group.
	It is probably helpful to reflect on the wider problem of savers. The savers who are currently most concerned are those who are on defined contribution pension schemes, and people who are getting private pension notices through their door every quarter and dare not open the envelope because of the damage that has been done by the halving of the value of the stock exchange. This is where the real haemorrhage of savings is taking place. He is right to focus on deposit accounts or those that carry interest, but that is only one corner of a much bigger problem.
	Before getting into the details of the policy, I want to try to look at the big macro-economic argument that flows backwards and forwards and which was unleashed by the Conservative leader's speech on savings a few weeks ago. There is a great danger of getting into a ludicrous caricatured argument that says on the one hand that spending is good, saving is bad, and on the other hand that saving is good, spending is bad. Lying behind a lot of the arguments we have that rather nonsensical polarisation of the argument.
	Of course it is necessary and right that we think about ways of building up long-term savings. We have an ageing population and it is essential that savings are built up for long-term care, for pensions and, for the younger generation, for deposits on homes, for higher education and much else. So of course we have to think about policies to encourage long-term saving. The problem that we have at present is a substantial difficulty that many people have because they are frightened. They are frightened because they have lost a lot of value in their savings, and they are frightened because of the loss of their job. Because they are frightened, they do not spend the money that they would otherwise spend and therefore hoard it. The purpose of policy in this world, whether it is cutting interest rates or fiscal policy, is to try to encourage them to be confident enough to spend that money. That is in no way in conflict with a sensible policy of encouraging long-term savings.

Vincent Cable: The general public's complaint is that the banks are neither fully passing on interest rate cuts nor benefiting their depositors; they are trying to build up their margins. They have to do that, but it has not been enough.
	I was glad that the hon. Member for Runnymede and Weybridge (Mr. Hammond) made it absolutely clear that he supported the policy of continuing low and falling interest rates. He was quite clear, so there is no point in my cross-questioning him about that. I am intrigued, however, because in debates I am often paired with the right hon. Member for Wokingham (Mr. Redwood), who gives a very good Conservative case; he is highly economically literate, and makes his case well. I think that he argues that interest rates should now be increased. I am glad that there is clarity about what appears to be a somewhat different approach starting from the same premises.
	As the motion rightly says, the problem is that people who have very low interest rates on their bank deposits feel that they are suffering and disadvantaged. I understand that. People in my constituency often come up to me and say, "Isn't this awful? What are we going to do about it?" Some points can be made to reassure them. First, if we are going into a deflationary environment—as we almost certainly are; that is what the Bank of England is warning us about—merely to have a bank account that is increasing in real value in a world of falling prices is compensation in itself. We have not got to that point, so people are not seeing it, but that is coming down the road.
	Furthermore—and this relates to the Equitable Life intervention—we should stress that all bank depositors have been fully protected: their deposits have been guaranteed and completely underwritten by the state, and in that they are unlike investors in many other forms of saving. Finally, many bank depositors are enjoying a reasonable rate of interest on fixed-rate deposits. I happen to be married to somebody who, as much through accident as through anything else, has ended up with a 6 per cent. fixed interest account in the Nationwide. She is laughing all the way to the bank. Many borrowers, however, are not getting the advantage of low interest rates. The balance of advantage between borrowers and lenders is not at all straightforward.
	Let me get to the heart of the issue. Given that savings are a problem in the long term, what should we do to help savers? I am thinking particularly of low-income savers, who are rightly the focus of the discussion. I was surprised that the hon. Member for Runnymede and Weybridge made no reference to one of the biggest sources of difficulty for low-income savers—the way in which the benefit system operates. People on pension credit effectively pay a 40 per cent. marginal rate of tax because of how the tapering system operates. For people on low incomes, saving is not worth while because they are penalised through the pension credit system.
	There is one particularly wicked inhibition on savings in the benefit system: if people with savings of £6,000 or more apply for pension credit, the Government assume that they are earning a 7 per cent. return on that account. That contrasts with 2 per cent. on main ISA deposits in national savings. Why is the rate 7 per cent., a penal disincentive to some of the poorest people in society? If we really tried to help people on low incomes with savings—that would come at a relatively low cost—we should address that anomaly. My colleagues did a calculation to the effect that about 500,000 really very poor people are being penalised £800 a year as a result of how the savings disregard system operates.
	There is common ground in the House on how we should look at savings reform. Like a lot of Conservative Back Benchers over the years, Liberal Democrats push for reform of the annuity system, which is a major discouragement to many forms of saving. I ask the Minister to reflect on one technical point. In this current banking crisis, the mutuals are essentially at a relative advantage because they do not have to worry about shareholder return. But the building societies often report that they are at a considerable disadvantage in attracting savers because they have to pay disproportionately for the cost of the depositor protection scheme. They seem to have a good point, albeit a technical one, and I should be interested to know whether the Government accept their case.
	Much more important than either of those two points is the fact that in order to save, consumers—savers—need to feel that they have a sense of protection and that they are not going to be ripped off by cowboys. We have had a couple of decades of endless scandals, with private pension mis-selling, endowment mortgages, split-cap trusts and, of course, Equitable Life. If people are operating in an environment where they know that their savings are not safe because they may have been mis-sold, they will not save. They must have very strong consumer protection in order that the savings culture can be revived.

Vincent Cable: We both did, but we did not succeed, and that was a loss. I entirely agree with that.
	In conclusion, let me focus on the key policy issue of tax relief. The Conservative spokesman again brought to our attention the recommendations of the Low Incomes Tax Reform Group, which has for many years been putting in very carefully considered recommendations that have been largely disregarded; I hope that they will now be taken seriously. The hon. Gentleman's main proposal is for a standard rate of tax relief on interest on savings accounts. We should consider that seriously. We are in the run-up to a Budget, it is a thoughtful idea, and we should on its strengths and weaknesses. I should point out, however, that when interest rates are very low it would be worth very little, for obvious reasons. It would benefit substantially only those with very large savings. A deposit of £100 at current interest rates probably attracts 40p in tax relief, while a deposit of £100,000 would attract £4,000 in savings, and that is where the benefits will go. I am not saying that it is a bad idea, but it operates primarily to the benefit of people in a high interest rate environment. I do not know whether the tax relief would continue when interest rates rose.

Doug Henderson: As the hon. Member for Twickenham (Dr. Cable) said, there is a risk in this debate that people might rant about economic policy. I am going to resist that temptation, and instead try to address the issue of how we should deal with savers in the current economic situation. I was disappointed in the hon. Member for Runnymede and Weybridge (Mr. Hammond), because a lot of his speech addressed the economic issues, and asked whether the Government were following the right course of action. I would like to reply to the points that he raised, but I will resist the temptation to do so now. However, those arguments have to be made. They have been made from our Front Bench, but I think that they should also be made from our Back Benches. The issue is whether we should do something, or do nothing, in response to the international economic crisis, but perhaps that debate is for another day.
	This debate is about saving. I come from a family in which thrift was considered to be the right approach. My mother was no economic expansionist. She put money into a tobacco tin every week. I think she was a bit of a hoarder, and she might well have been encouraged by the present culture of holding funds rather than taking a risk on investments. That approach might have been in her interest, and even in the interest of the family, although I am not sure it would have been in the interest of the economy generally, had it been followed by everyone else in our village.
	First, on a point of principle, is it always right to save? The answer is no, it is not. There are times, as the hon. Member for Twickenham said, when it is important to have high levels of spending; at other times, it is important to have high levels of saving. The imbalance in the world economy is because countries such as China have too high a savings ratio, while countries such as the United States and Britain have had too low a savings ratio over a long period of time. We need to get that back into balance.
	Like many other Members, I have had letters from constituents saying, "I have been thrifty all my life. I have worked hard and put money away, and I expected it to supplement any pensions that I had when I retired. Now, I look at the return that I am getting, and it is so low that I feel as though I have lost everything. What are you, as a Member of Parliament, going to do about it?" We have to be realistic. We cannot promise what is not on. The failure of the Conservatives' proposals today is that, in the present circumstances, they are the wrong ones. They would give a false sense of hope to the people in all our constituencies who are saying that they have lost their life savings. They have not lost capital sums, but they have lost the revenue that was being generated from those capital sums.
	The problem with speaking after the hon. Member for Twickenham in a debate is that he steals a lot of the arguments along the way, but he was right in what he said about what would happen if the Conservative proposals were put into practice. I do not know what the average return is on a savings account today—I would be interested to know whether the Treasury has any figures on that—but let us say that it is 2 per cent. Actually, I would say that that was generous. In the opening speech from the hon. Member for Runnymede and Weybridge, a figure of £10,000 a year investment income was mentioned. That is not a lot of money, but to generate that now would require a huge capital sum—possibly £500,000, on the figures that I have given. It could be even more, as I do not think there is an average 2 per cent. return on savings at the moment. Only a very small group of savers has that kind of capital to invest.
	The Conservative proposals would not help the poorer pensioners who are suffering from our economic ills at the moment, although they have had assistance from the Government, which is very welcome. The proposals would not address the problems of the poorest 60 per cent. of pensioners, or the many savers in our constituencies who have been getting in touch with us. If their savings income is very low, it does not matter how much tax relief we give them; it would be of very little benefit.
	The Conservatives' motion calls for their proposals to be geared to the period in which we are pulling out of the recession. I am not sure that that would be wise either. The only way in which we can get higher levels of economic activity in this country is through higher levels of spending. That could be Government spending, private sector spending or a combination of the two. However, giving additional incentives to savers is not the right course of action at the moment because, on account of low returns on investments, it does not give any benefit to the people we are trying to help. When the economy begins to gather momentum and we begin to look to recovery would not be the time to adopt a policy to encourage saving in this country. The time to encourage saving is when we move back to a higher level of economic activity, whatever that is and whenever that may be. At that point we will need to make changes, for example, we need to reform our savings taxation structure, and it might then be appropriate to adopt some of the other policy changes that have been suggested. I do not know; it depends what the alternatives are, but the provision of additional incentives to savers is certainly not the appropriate policy at the moment.
	The Conservatives have made that policy suggestion because they think that there are a lot of votes to be gained from traditional savers who are disillusioned by their current circumstances. That policy will not offer any significant help to those savers, and it is a con-trick and politically dishonest of the Conservatives to suggest otherwise. I do not have any bright ideas about this matter, but we have to look at other ways of giving help to those who have saved over the years and who are now in a difficult position.

Richard Spring: All human beings have a powerful instinct to save—for their families, for themselves and for their retirement. Unfortunately, during the last few years, a disproportionate amount of saving has gone into bricks and mortar. It is as simple as that. The consequence is that people's reserves of actual saving have declined absolutely and relatively, and now that we are in a grievous economic situation, people cannot easily cope. That is the simple truth about what we face today. We are in a debt crisis. There is far too much personal debt, banking debt and Government debt. I would like to touch briefly on the personal debt and savings situation, which is so dire.
	According to Credit Action, a national money education charity, during 2008 Britain's personal debt increased by £1 million every 10 minutes, 124 properties were repossessed every day and one person was declared bankrupt or insolvent every 4.8 minutes as an exact consequence of what I just mentioned. Household debt has grown enormously higher than that of virtually every other country, even the United States, with which we share certain economic similarities. The UK's overall household debt has now overtaken UK GDP. It currently sits at 109 per cent. of GDP—the highest in the G7. According to the chief economist of Citigroup, not only is it the highest in the G7, but the highest any G7 country has ever seen. That is the background to the current situation. Business interest repayments in personal debt have soared to £92 billion in the past 12 months. It is therefore absolutely essential in the long run that big changes are made. We need to move from an economy that this Government have built entirely on debt to one that is built more in a traditional way on savings. Britain needs to be encouraged to save for the future rather than to get further into debt, with all the consequences that we have seen. Unfortunately, the culture of saving is increasingly being replaced by a culture of dependency.
	We have heard the statistics about the level of saving. In 1997 it was 9.9 per cent., and the latest figures suggest that it has now declined to 1.8 per cent. One might ask whether there is anything particularly unusual about that worldwide. OECD figures show that our savings ratios are far worse than those of almost all other industrial countries. The result is that in the current economic climate, many families across Britain are going into the recession without any real savings cushion.
	Statistics published by the Alliance & Leicester reveal that 13.5 million Britons—28 per cent.—did not save at all in 2008. The same survey reveals that 18 per cent. of people dipped into their savings more last year to meet extra costs and bills, and the projection of attitudes in the coming year is even worse. The amount saved as a percentage of income has declined every autumn since 2005.
	Being able to save money to provide future stability and security should not be exclusive to the affluent. No matter the size of their income, everybody should be encouraged to save. AXA has produced extraordinary figures showing that amazingly, the only group of people who can save given the current financial and economic pressures are those earning more than £70,000 a year. That reflects the terrible squeeze on middle and lower-income earners, who have suffered grievously as a result of the interest rate reductions on their savings. The debt situation of 18 to 34-year-olds and people with mortgages also shows that the pressure is on.
	The importance of families having savings cannot be stressed enough, yet according to research for MoneyExpert, nearly a third of adults would face financial disaster within two months if they lost their jobs. Half of them believe that they would last only a month. Given the tragedy of huge unemployment that is besetting us, we can see the consequences of such frightening statistics. We know about the decline in private and company pension scheme contributions, which have plummeted by 53 per cent. in the past 18 months, and people's fears about their savings and pensions are stronger than ever. In his 2008 Budget, the Chancellor mentioned that the Government were
	"committed to encouraging more people to save."—[ Official Report, 12 March 2008; Vol. 473, c. 291.]
	There is absolutely no evidence that that is the case—quite the reverse.
	By 2012, our national debt will be approaching £1 trillion, which means that for years to come there will be a debt burden and an interest rate burden on anyone wishing to save. The Bank of England has stated that deposit accounts now pay average interest of less than 1 per cent., and there is very limited attraction to individual savings accounts and other such accounts in the current circumstances.
	I simply wish to make the point that we need to cut taxes for savers in the current economic climate, to help turn Britain from a spend, spend, spend society into a save, save, save society in the long run. As John Varley, the chief executive of Barclays, said last week,
	"the Government needs to create a tax incentive for saving."
	At least the Conservative party is putting forward plans to try to encourage exactly that process.
	Many older savers who have acted responsibly during the years of irresponsibility now feel threatened and penalised, as Age Concern has commented. My hon. Friend the shadow Chief Secretary has set out exactly what the incentives should be, and I say simply that this is a matter of urgency. The tax incentives that we are offering to encourage saving should not be delayed. I urge the Government to listen carefully to what my hon. Friend says and adopt those measures in the forthcoming Budget, for all the reasons that I have given. They should not delay, for the sake of the future of this country and the stability and sense of security of millions of savers of all ages and from all groups in Britain.

Emily Thornberry: If we are to discuss savers' interests at such a time, we must begin by examining the context, which is the international financial turbulence. If nothing had been done in Britain, the banks would have collapsed and most of our savers would have lost everything. If we are to consider the effects of economic policy on savers, we should begin there.
	The Government have not only taken action to save the British banking system and to work with others to fight the downturn in the international finance market, but we have recapitalised the banks, which stabilised the banking system when it was on the brink of catastrophic collapse. We are now making further agreements with banks to get them lending again to get us through this period and out of the recession as quickly and with as little pain as possible.
	Our taking action last year and ignoring the Conservatives' pleas to do nothing meant that no individual saver in this country lost any money. The Conservatives now try to make political capital out of the difficulties by waving before us problems that savers may be suffering. We should ignore the Conservatives' crocodile tears. It is hard to take them seriously when one remembers the Leader of the Opposition—the man in the shadows— advising Norman Lamont, who was Chancellor of the Exchequer when interest rates were 17 per cent. What help was that to savers?
	It is hard to take Conservatives' crocodile tears seriously when they talk about helping savers, yet savers on less than £30,000 would benefit from the proposed changes by less than £5 a year. It is hard to take those crocodile tears seriously when 60 per cent. of pensioners would not benefit from the plans because they do not pay taxes. It is hard to take seriously Conservative Members' crocodile tears as they claim that they want to help savers, when that means that they would cut investment in public services during a downturn. That is economically illiterate.
	Whatever help we may wish to give middle-income savers, I hope that we get assurances today that any such help will come when we are able to give it and not be at the expense of slowing public spending. Cutting public spending at such a time means undermining vital services, which help the poorest and those in most need.
	The Conservative proposal would offer only limited help to some by cutting support and services for others, including those who need it most. The Leader of the Opposition has said that he would fund his idea by cutting investment in new Departments, but the figure given today was £4.1 billion. Where will that come from? Does it mean cutting the Department for Work and Pensions, when unemployment is unfortunately likely to increase? Does it mean cutting that Department to say good-bye to the proposed 220,000 apprenticeships? Does it mean cutting the new homes for social rent, when there are plans for another 10,000? Does it mean cutting investment in infrastructure, such as Crossrail? Surely it is not the time, when unemployment is unfortunately likely to increase, to cut infrastructure projects.
	I appreciate that we are speculating about the jobs that Conservatives are contemplating cutting to raise the money, but we get no details from them, so they can hardly blame us for speculating on the effects of restricting Government budgets. We are told that the proposal will cost £4.1 billion, but if we cut back 1 per cent. of all the budgets, we would still be £500 million light. It has not been thought out. If one examines the way in which it was presented to the media, and considers the context in which David Cameron gave his answer—

Brooks Newmark: Under the Government's current economic policy, prudence seems to go unrewarded. Regrettably, the Government have still not reacted to the devastating consequences that interest rate cuts have brought to a generation of savers. The Government may be offering bail-out after bail-out to over-leveraged banks. However, they are failing to help, if not reward, those in our society who have put aside money in the form of savings, especially the more vulnerable in our society, such as pensioners, who are now seeing their standard of living drop daily.
	We need a savings culture at the heart of our economy if it is to grow out of this recession. Thrift and prudence will ensure confidence and the ability to invest in the future. However, recent economic policy has only consolidated a longer-term trend that has emerged under this Government. That trend, which was exemplified by the Prime Minister when he was Chancellor, is towards a Government built on a mountain of debt and indulging in their own spending binge. Encouraged by the Government's poor household financial management, ordinary individuals have gone on a borrowing and spending binge too. The result is that in 2007 the household savings ratio fell to less than one third of what it was in 1997.
	Cutting interest rates was indeed the right thing to do to deal with the current crisis. However, hanging savers out to dry in the process is completely unacceptable. We have now seen seven consecutive interest rate cuts—that is seven consecutive hits on savers and seven opportunities lost by the Government to give help to those who need it. Instead of looking after savers, the Government have written a blank cheque for the banks—many of them the very institutions that helped to create the economic mess. With taxpayers' money keeping them afloat, those same banks continue to slash interest rates on savings accounts, which have reached as low as 0.1 per cent. for some instant access accounts.
	Savers and borrowers are confused about how to play the game of interest rate roulette. With low returns on savings, high borrowing costs and interest rate cuts not being passed on to borrowers, people simply do not know what to do. With poor savings rates on offer and a drop in confidence in the banks, it is projected that 45 per cent. of people are less likely to save in the next three months. What is it that people save for? They save to put a deposit on a house, help provide care for themselves in old age or send their children to university. Without savings, none of that can happen, which will have grave consequences for our economic recovery.
	The Government may claim that their economic policies are offering real help to the people who need it most, but unfortunately those polices have failed to help the most vulnerable in our society—the poor and the elderly. With interest rates not expected to rise again in the near future, the Government must urgently create incentives to save again. Even bank bosses agree that we need tax incentives for our savers.
	I thus ask the Minister at least to reflect on the proposals of my right hon. Friend the Member for Witney (Mr. Cameron) and the shadow Chancellor my hon. Friend the Member for Tatton (Mr. Osborne), as outlined in this debate by my hon. Friend the Member for Runnymede and Weybridge (Mr. Hammond): to reduce to zero the 10p starting rate and the 20p basic rate of tax on savings, so that basic rate taxpayers pay no tax at all on their income from savings, thus helping them by up to £7,200 a year; and, secondly, to increase age-related personal allowances by £2,000 for those aged 65 and over, benefiting them by up to £400 a year.
	To conclude, this debt-addicted Government are doing nothing for those who have been more prudent than themselves. To borrow more money to get the country out of its problems, according to Dr. Tempest, is a bit like telling a heroin addict that he needs more heroin in order to recover. This country does not want a legacy of debt; it needs a culture of saving and a Government who are willing to take urgent action to make it happen.

Mark Hoban: We have had a generally thoughtful debate about savings in the UK economy and the impact of the current economic crisis on savers.
	My hon. Friend the Member for West Suffolk (Mr. Spring) gave an analytical view of the current state of the savings market, and provided a helpful backdrop to later contributions.
	My hon. Friend the Member for Braintree (Mr. Newmark) set out very clearly the need for saving in the long term and why people should put some money aside for the future. My hon. Friend the Member for Shrewsbury and Atcham (Daniel Kawczynski) pointed out in his contribution on Equitable Life what happens when things go wrong. There has been an undue delay in helping policyholders in Equitable Life, which has consequently eroded the confidence of savers in the saving market. We need to bear that in mind.
	The hon. Member for Poole (Mr. Syms) talked about the dependence on the wholesale market for funding in recent years. I will come to that later, but he is absolutely right that the savers' culture must be rebuilt to ensure that banks are less dependent on wholesale markets. That would make a significant contribution to increasing the stability of the economy as a whole.
	The hon. Member for Twickenham (Dr. Cable) broadly supported some of the ideas that we have put in our motion today, and I am grateful for that.
	The hon. Member for Newcastle upon Tyne, North (Mr. Henderson) said that there is nothing in the measure to help the poorest. I want to point out to him a comment that has popped up two or three times in the course of this afternoon's debate. There are people who have a savings income who pay no tax—or tax at only the 10 per cent. rate—who receive their savings net of tax and often do not know how to reclaim that tax. They are losing out. There is something in the policy for them, as it will make it easier for them to ensure that they receive their interest on a gross basis.
	The hon. Member for Islington, South and Finsbury (Emily Thornberry) talked about how we would fund the policy. We have made a very clear proposal on how we would fund the tax reductions. We believe that that it is in the interests of the economy as a whole for that to take place.
	The hon. Member for Leeds, East (Mr. Mudie) objected to the motion because it might be too political—I thought that the House of Commons was here to talk about the political issues. He alighted on a particular point that has raised concern among Members on both sides of the House, which is the rate of interest that is assumed for the calculation of pension credit. People might want to return to that topic and to think about it.
	The hon. Member for Luton, North (Kelvin Hopkins) gave one of his typical speeches about the rate of tax. Let me point out to him that we have a state savings bank in National Savings and Investment, which raises money to help offset the national debt. It has been tasked with increasing the amount of money that it is to raise from savers this year. A state savings bank already exists, and that was perhaps the only point of agreement between us in our discussion this afternoon.
	We need to return to the central point. Although it is right to tackle the recession using monetary policy and it is right to reduce interest rates, we need to remember that although low interest rates help to ease the position of borrowers, savers pay the price. As the returns on their ISAs and building society accounts tumble, so does their income. At a time like this, it is right to help those people who depend on interest income. That is why our policy to scrap the basic rate of tax on interest for basic rate taxpayers is designed to help savers today. It will reward people who have done the responsible thing through the last decade and have put money aside. It will help to cushion them from the fall in interest income that they will have seen over the course of the past few months.
	Our policy is not just a short-term policy. It is a policy for the long term. It is not just about helping people who are living off savings today, but about encouraging people to save in the long term. Over the course of the last decade, the Government have presided over a collapse in the savings ratio. As part of the golden economic legacy that the Government inherited in 1997, the savings ratio was 9.9 per cent. It has fallen to 1.8 per cent. In 1997, people saved £54 billion. In 2007, that figure was down to £20 billion. When the Government came into office, one in 10 families had no savings. The most recent figures show that one in three families have no savings.
	We are paying the price for the casual attitude that the Government have shown towards savings over the past decade. People are entering the recession ill prepared for the strain on their finances. The collapse in the savings ratio means that people with low savings are likely to face more financial distress. They do not have the money for a rainy day, the cash for an unexpected expense, or the buffer that will tide them over a period of unemployment or of short-time working.
	The Government's amendment shows that they have been complacent. The measures that they have introduced, such as the child trust fund and the savings gateway, are so far unproven. They have not tried to encourage savings across the country as a whole.
	The price of that complacency has been borne by families and business. Savings are the bedrock of family finances, but they are also the foundations of a stable economy. Without adequate UK savings, borrowers become increasingly dependent on the flows of capital into the UK. At the start of this decade, bank deposits broadly matched the amount of lending required in the economy. Cash in the bank was enough to fund loans to families and businesses, but the story of the decade has been that borrowing has risen without being matched by savings or bank deposits. Instead, it has been funded through international wholesale markets. In December, the Bank of England believed that the funding gap was £740 billion. That means that we need to find three quarters of a trillion pounds to fund borrowing at current levels.
	The collapse of Northern Rock showed the perils of dependence on wholesale markets, which triggered the bank's collapse—

Ian Pearson: For the most part, this has been a thoughtful debate, and to that extent I agree with the hon. Member for Fareham (Mr. Hoban). We had some good contributions from my hon. Friends the Members for Newcastle upon Tyne, North (Mr. Henderson), for Islington, South and Finsbury (Emily Thornberry), for Luton, North (Kelvin Hopkins) and for Leeds, East (Mr. Mudie), and contributions also from the hon. Members for West Suffolk (Mr. Spring), for Braintree (Mr. Newmark), for Shrewsbury and Atcham (Daniel Kawczynski) and for Poole (Mr. Syms).
	Since the Labour Government came to power in 1997, we have a savings record that we can be proud of. We have taken a number of steps to encourage saving. The system of individual savings accounts that we introduced in 1999 has been highly successful. As hon. Members know, around one in three British adults hold an ISA, and only last year we acted to make ISAs even more attractive to potential savers, making them more flexible and easier to use and raising the annual tax-free investment limit to £7,200.
	The child trust fund that we introduced provides every child with £250 at birth, or £500 for children in lower income families, and again at the age of seven. The policy is designed to strengthen the saving habits of future generations, promote financial inclusion and ensure that at age 18 every child will have access to a financial asset. We are delighted that more than 4 million children now hold a child trust fund account.
	We are implementing a new scheme, the savings gateway, which we hope will come into operation in 2010. The savings gateway is a cash savings scheme that aims to promote saving and financial inclusion for those on lower incomes, and it provides a financial incentive to save through a Government contribution of 50p for each pound saved in the scheme, up to a monthly limit. The scheme has already been positively piloted and it will help kick-start the saving habit among those who have not saved before, as well as helping those who are currently excluded to enter the financial mainstream. Furthermore, pensions tax relief of £30 billion gross is available.
	The hon. Member for Runnymede and Weybridge (Mr. Hammond) fails to give credit where credit is due. By all means let us debate the savings-related issues that exist between our parties, but let us not forget that there are savings products out there that are benefiting individuals throughout the country. On the off-chance that a saver has tuned into the debate or might Google it at a future date and might want advice from hon. Members who participated in the debate, let me say that the Financial Services Authority, through its money made clear website, provides impartial, jargon-free advice. Many savings products on the market offer competitive rates and good deals.
	It took the hon. Member for Runnymede and Weybridge 25 minutes to get on to the subject of saving. He started with a number of assertions, the most outstanding of which I found to be the assertion that there was an emerging consensus that a fiscal stimulus was not appropriate. I do not know who the hon. Gentleman has been talking to, but I do not believe that there is even a consensus on the subject in the new shadow Cabinet. The Conservatives are isolated in Europe, the United States is looking to introduce a further fiscal stimulus under its new President, the Germans recently announced a fiscal stimulus, and other countries are doing so.
	When the hon. Gentleman pooh-poohs the Government's VAT cut—

Ian Pearson: I did not say that I agreed with the shadow shadow Chancellor on everything. He was right that the VAT cut is a most effective policy instrument, and we believe that this is making a difference. This is pounds in people's pockets now. The average family will save something in the region of £275 a year as a result of the Government's VAT cut, and that stands in stark contrast to the Tory tax proposals on savings, which will save the average family £5 a year.
	The hon. Gentleman also needs to talk to his shadow Chancellor when he said earlier that higher rate taxpayers will not benefit from the proposals. My understanding of what the shadow Chancellor said on "Money Box" is that they would, and that higher rate taxpayers will get the 0 per cent. rate and the basic rate up to the top of the basic rate savings on their income, because savings are taxed like any other forms of income. I believe that the current proposals are effectively targeted. As he is aware, 60 per cent. of pensioners do not pay tax at the moment. Through ISAs people can save up to £3,600 a year in cash at the moment as a result of the Government's policies. When he talks about the savings ratio, he ignores the fact that in 2007 the savings ratio was 3.4 per cent. as a percentage of GDP, pretty close to the 3.7 per cent. average that we have seen during the last 20 years, and certainly higher than that of a number of other countries, notably the United States, but also Japan and Italy.
	The hon. Member for Twickenham (Dr. Cable) made a typically thoughtful speech and I agree with him totally that we should not be polarising the argument: saving is good, spending is bad, or spending is good, saving is bad. He made a couple of technical points, one about the depositor protection scheme, on which I wanted to reply to him, because I appreciate the building societies' concerns in this matter. He will be aware that members of the Financial Services Compensation Scheme pay statutory levies in proportion to the size of their protected deposits. They benefit in the good times and it is right that they contribute in the bad times.
	The hon. Gentleman also made a point about pension credit, and I think he talked about the 7 per cent. rate. We have not assumed a 7 per cent. interest rate, if I heard him correctly on this matter. Pension credit rules are more generous than those of the previous minimum income guarantee, and they assume a notional rate of income at a rate of £1 for every £500 or part of £500 savings held above the threshold. I hope that that clarifies the matter.
	It was suggested that only the wealthy could afford to save. One in five people from low-income groups have an ISA compared with one in seven who used to have a TESSA or a PEP. People are saving through the child trust fund, and a third of those who save through save as you earn programmes earn £21,000 or less.
	Since the Labour Government came to office, households are on average £1,250 a year better off in real terms. The poorest 20 per cent. of families are £4,100 a year better off. Whether it is through ISAs, personal pensions, the child trust fund, the forthcoming saving gateway scheme or higher rate tax thresholds for pensioners, we have put in place incentives for saving for everyone at every point in their lives.
	I urge hon. Members to support the amendment in the name of the Prime Minister.
	 Question put (Standing Order No. 31(2)), That the original words stand part of the Question.
	 The House proceeded to a Division.

Patrick Cormack: On a point of order, Mr. Deputy Speaker. I was standing at the Bar of the House when my hon. Friend the Member for Shrewsbury and Atcham (Daniel Kawczynski) raised his point of order, of which I had no knowledge at all. It seems to me, Sir, that you are representing Mr. Speaker. Should the matter not be referred immediately by you to him?

Mr. Deputy Speaker: The House will have heard the point of order that has been raised. Both Front Benches have heard it, too. I can clearly report the matter immediately to Mr. Speaker and he will take whatever action he deems appropriate. That is all that we can do for the time being. My advice to the hon. Member for Shrewsbury and Atcham was on the course of action that he should take. I was not advising him of the course of action that I will take, which is as described by the hon. Gentleman.

Motion made, and Question put forthwith (Standing Order No. 118(6) and Order of 9 December),
	That this House takes note with approval of the Government's assessment as set out in the Pre-Budget Report 2008 for the purposes of Section 5 of the European Communities (Amendment) Act 1993.— (Ian Lucas.)
	 The Deputy Speaker's opinion as to the decision of the Question being challenged, the Division was deferred until Wednesday 28 January (Standing Order No. 41A).

Peter Atkinson: The petition is signed by 86 of my constituents.
	The petition states:
	The Petition of small shareholders and supporters of Northern rock of the Hexham constituency in the North East of England,
	Declares that it welcomes the acknowledgement by the Government that it must pay compensation for nationalising Northern Rock plc, but that the terms of reference for the valuation of the shares are wrongly based as the company was not in administration and was still a "going concern".
	Further declares that if these terms are unchanged there will not be a fair compensation payment which will lead to many in our region having their savings and pensions undermined which in turn will have a negative impact on the North East's economy.
	The Petitioners therefore request that the House of Commons calls on the Government to reconsider the terms of reference given to the valuer so that he can fully reflect the true value of Northern Rock shares.
	And the Petitioners remain, etc.
	[P000298]

Janet Anderson: I thank you, Mr. Deputy Speaker, and Mr. Speaker for giving me the opportunity this evening to raise this issue, which is of great importance to my constituents.
	In the 19th and early 20th centuries, before the advent of vaccination, the most common causes of death and disability in this country were infectious diseases such as smallpox, diphtheria, tetanus, whooping cough, measles and polio. The average life expectancy of a male baby born in 1900 was 45. Edwardian men considered themselves old in their early 40s. Our pursuit of the maxim that prevention is better than cure has been successful: it has changed the structure and quality of our lives, but much more remains to be done. Often, if we solve one set of public health problems, the next challenge looms clearer.
	The main cause of death in the UK now is cardiovascular disease and coronary heart disease, with nearly half the deaths caused by the latter. Based on 2005 data, there are some 227,000 heart attacks each year. The British Heart Foundation estimates that 1.5 million men and 1.1 million women are living with CHD. That is an immense residual quantum of personal suffering, but also a burden on the economy. It is reckoned that coronary heart disease costs the UK economy nearly £9 billion a year, and £5.7 billion of it is a result of days lost owing to death, illness and informal care costs.
	What is the best medical handle to bear down on this? Well, we know that high blood cholesterol is the single biggest risk factor. It was from that finding that a strategy began to be put in place to address the problem. In April this year, the Department of Health launched "Putting Prevention First"—a national programme of vascular checks for 40 to 74-year-olds, including risk assessment and management. It is thought that that programme has the potential to prevent up to 9,500 heart attacks and strokes every year and to save no fewer than 2,000 lives.
	Running in tandem with that is the key part of the mechanism: the annual reward and incentive programme based on GP practice achievement results. That is the quality and outcomes framework, which began in 2004 and is known as the QOF. The current QOF target is to get 60 per cent. of all identified patients to a target cholesterol level. However, there are elements within the overall control strategy that are not operating optimally—at least not yet. A report by the university of York of June 2007, which I commend to hon. Members, dealt with
	"the link between healthcare spending and health outcomes",
	and reads:
	"Recent developments in circulatory drug therapy (especially statins) are acknowledged to be highly cost effective",
	but we do not make full use of them. Our death rates from cardiovascular disease remain among the highest in western Europe. Tony Hockley, director of the Policy Analysis Centre, reckons that in England alone there are more than 7,000 unnecessary heart attacks a year because we do not diagnose and treat enough people with raised cholesterol levels.
	I understand that cholesterol testing in the US is recommended for all adults over 20 every five years, that US targets for cholesterol reduction are significantly more ambitious than in the UK and that, broadly speaking, the hard-headed medical insurance companies in the US are prepared to pay for cholesterol-reducing medications on a preventive basis for those in high-risk groups. What makes sense to commercial ventures in the USA should make sense to a value-for-money-minded Treasury in the UK, too.
	The big problem with QOF is that it has not moved with the times. The 2004 measure was based on recommendations made in 2000. There are inconsistencies with the National Institute for Health and Clinical Excellence guidelines of 2008 and the Joint British Societies professional guidelines. The 2008 NICE guidelines on lipid modification and type 2 diabetes recommend a level of cholesterol in the blood 20 per cent. lower than the QOF provides for, but, as yet, the target remains static. That means that the way in which we pay GPs is not incentivising them adequately to treat patients down to ideal serum cholesterol levels. That represents a missed opportunity, and lives lost or blighted.
	There is an additional anomaly. GPs can still qualify for their QOF incentives even if significant numbers of patients are excluded from the calculations under the exception reporting rules. That is fair up to a point. Practices should not necessarily be penalised if, for example, patients do not attend for review, or if a medication cannot be prescribed because of contra-indications. However, the exception reporting rate for cholesterol control varies widely in primary care trusts, from some 5 per cent. to 15 per cent. Worse, 14 of the 40 PCTs with exception reporting rates above 10 per cent. are also meant to be "spearhead PCTs", and therefore to be leading a drive to tackle public health problems such as smoking, obesity and poor diet in some of England's most deprived areas. My own PCTs, Blackburn with Darwen and East Lancashire Teaching, have an exception reporting rate of 12.8 per cent. and 11 per cent. respectively. We are left with more than a suspicion that the exception reporting rules are being used in a way that preserves GP income but does not maximise health service delivery, not least in the most deprived areas of the country.
	The message is clear: the mechanism by which we incentivise GPs to deliver health improvement is outdated. It needs review, not least in bearing down on high exception reporting rates. As a nation, we invest a great deal in the NHS and we have a right to expect value for money and achievable goals in driving down rates of the main killer disease in Britain today.
	I thank the Minister for attending today. She has previously expressed an interest in this topic in answer to parliamentary questions, and I look forward to hearing her response.

Ann Keen: I congratulate my hon. Friend the Member for Rossendale and Darwen (Janet Anderson) on securing this important debate. Heart disease is exceptionally important for all of us who work in health, because the advances in addressing it have been overwhelming, as my hon. Friend described at the beginning of her contribution. My father died of coronary heart disease at the age of 57 some 30-odd years ago, and possibly he would be alive today if there had been the advances then that we now see so regularly in our NHS.
	Appropriate and targeted services for the treatment of coronary heart disease are, of course, vital. I am advised that in the Blackburn with Darwen primary care trust area, which covers part of my hon. Friend's constituency, mortality under the age of 75 from all circulatory diseases was significantly higher than the England and Wales average during 2005-07. Despite falls in circulatory disease mortality under the age of 75, it remains a leading cause of premature death both nationally and locally. In Blackburn with Darwen it accounted for more than one in three premature deaths in men and almost one in four in women in 2007. In the Lancashire area, which also covers my hon. Friend's constituency, there has been a decrease in the early death rate from heart disease and stroke, but it still remains above the England average.
	Nationally, coronary heart disease is the biggest cause of death in England, responsible for more than 110,000 deaths every year, and it costs the economy more than £7 billion annually. But the cost to the families involved—the mums, dads, daughters and sons—cannot be counted. In most instances we are talking about sudden death, and no one can say that people can recover from such a thing happening in their family. As a former nurse, I have often had to break bad news to relatives in this situation, and I have sometimes tried and failed to save someone's life.
	It is vital that frameworks are put in place both nationally and locally to address the financial and personal burden of cardiovascular disease. We have made tremendous progress in tackling the challenges of heart disease over the past 10 years. The national service framework for coronary heart disease set a 10-year framework for action to prevent disease, tackle inequalities, save more lives and improve the quality of life for people with heart disease. It set a framework to deliver quality services that are responsive to the needs and choices of patients.
	I am pleased to report that the target set out in Our Healthier Nation to reduce the number of deaths from cardiovascular disease in people under 75 by 40 per cent. by 2010 was met five years early. Furthermore, the mortality rate fell by 44 per cent. between 2005 and 2007, compared with the 1995 to 1997 baseline. I pay tribute to all in the national health service who have achieved that target so many years in advance; it was met in 2008, rather than in 2010. That is something to be proud of when celebrating 60 years of the NHS.
	One example of an initiative that has saved lives is the installation of 681 defibrillators in busy public places across the country, saving the lives of at least 93 heart attack patients. Indeed, my colleague in the Department of Health, Lord Ara Darzi, practised saving lives very successfully some time ago by using a defibrillator in the other place when a Member of the House of Lords was taken ill. These improvements have required significant investment in the prevention and treatment of coronary heart disease. Some £613 million has been spent nationally on providing new or expanded heart surgery hospitals across the country, and £122 million has been invested in improved diagnostic and treatment facilities. The investment supports the building and equipping of 90 new or replacement catheterisation laboratories—I have had the pleasure of visiting such units at Harefield, King's College and St. Peter's in Chertsey in the past few months—and that has met a real need to act fast not only when chest pain arrives, but when coronary arteries are diseased and that is shown through the angiogram process.
	Furthermore, we now have 61 per cent. more cardiologists and 46 per cent. more cardiothoracic surgeons than in 1999. In the north-west region, the Lancashire cardiac centre was a £52 million capital development project, commissioned to serve the residents of Lancashire and south Cumbria. The centre includes three cardiac theatres, three catheter laboratories, eight ward beds and 14 intensive care unit beds. About 3 million people are receiving statins—my hon. Friend mentioned those cholesterol-lowering drugs—and that has saved an estimated 10,000 lives every year. Statins are now also available over the counter, rather than solely by prescription, thus enabling more people to benefit.
	I am so proud that the NHS and Department of Health have narrowed the gap in coronary heart disease between the most deprived areas and the national average by 32 per cent. We remain on track to meet the 2010 target of at least a 40 per cent. reduction. When the quality and outcomes framework—QOF—was introduced as part of the new GP contract in 2004, it was a pioneering approach to improving quality of care by rewarding GP practices for how well they care for patients, not just how many patients they have on their list. The Commonwealth Fund Survey published in November 2006 found that GPs in the UK are leading the world in the efficient management of chronic disease and the uptake of financial incentives to improve the quality of services.
	The latest figures for the QOF show that practices have continued to deliver improvements in services for patients. We are also making real progress in addressing health inequalities between affluent and more deprived areas. We want the QOF to continue to support GP practices in delivering outcomes for patients that are among the best in the world. This is key to the vision developed in the primary and community care strategy, working closely with leading GPs and other health care professionals, as part of the NHS next stage review. That will be possible only if the QOF is continuously reviewed to reflect up-to-date evidence of best practice.
	The Department is therefore asking the National Institute for Health and Clinical Excellence to lead a new independent and transparent process for developing and reviewing the evidence base for QOF indicators from April 2009, as part of its role in providing guidance to the NHS based on evidence of clinical and cost effectiveness. A consultation document was published on 30 October 2008 to consult widely with patients, carers, NHS professionals and commissioners on how the new process should work. The consultation process is due to close soon, on 2 February.
	My hon. Friend mentioned concerns about exception reporting. The overall exception rate for England reduced from 5.83 per cent. in 2006-07 to 5.26 per cent. in 2007-08. Independent research shows that practices in deprived areas are slightly more likely to exception-report patients than practices in affluent areas—I believe that the difference is less than 1 per cent. The research concludes that GPs in deprived areas achieved high QOF scores without high rates of exception reporting, and the differences in scores between affluent and deprived areas are small and of relatively little clinical significance.
	Our proposals for a new independent and transparent process for reviewing QOF indicators are intended to build on the QOF's ability to help reduce health inequalities and respond to the needs of our diverse society. There is evidence from research that some practices, whether in deprived or more affluent areas, may be using exception reporting inappropriately. Manipulating QOF data in order to increase rewards without delivering the required level of quality for patients is clearly unacceptable, and also unfair on the majority of practices, which comply with QOF requirements.
	PCTs are responsible in England for verifying evidence for QOF achievement. They should analyse exception rates as part of this, investigating any outliers, correcting QOF payments where necessary and taking action if they uncover any actual fraud. I stress that fraud is the exception. We have provided guidance and training for PCTs on examining exception reporting as part of QOF assessment and verification.
	The past 10 years have seen significant and tangible progress in cardiac services nationally, and I am keen for them to continue to improve. Our smoke-free policies have made a huge difference, but it is critical that we start early, with our young children and teenagers, in emphasising the need for a healthy lifestyle. I thank my hon. Friend for bringing this important issue to the attention of the House today, and I am glad to have been able to give her such a positive response.
	 Question put and agreed to.
	 House adjourned.